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2020

FAMILY ENVIRONMENT AND ATTACHMENT IN RELATION TO

COMPLEX TRAUMA AND C-PTSD
Susan Elizabeth Ocean
University of Montana

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 FAMILY ENVIRONMENT AND ATTACHMENT
IN RELATION TO COMPLEX TRAUMA AND C-PTSD

By

SUSAN ELIZABETH OCEAN

Master of Arts, University of Montana, Missoula, MT, 2014

Bachelor of Science, Old Dominion University, Norfolk, VA, 2009

Dissertation

presented in partial fulfillment of the requirements

for the degree of

Doctor of Philosophy
In Psychology

The University of Montana

Missoula, MT

August 2020

Approved by:

Scott Whittenberg,
Graduate School Dean

Christine Fiore, PhD, Chair

Department of Psychology

Cameo Stanick, PhD

Department of Psychology

Paul Silverman, PhD

Department of Psychology

James Caringi, PhD

School of Social Work

Rick van den Pol, PhD

Department of Psychology
Ocean, Susan, Ph.D., August 2020 Psychology

Family Environment and Attachment in Relation to Complex Trauma and C-PTSD

Chairperson: Christine Fiore, Ph.D.

Childhood traumatic experiences occurring during critical developmental stages are strongly
linked to poor mental health outcomes during adulthood, including PTSD. Yet, individuals who
have experienced multiple traumas (and across developmental stages) report a profile of
symptoms that is not well-represented by traditional PTSD diagnostic criteria. Recent research
suggests that resulting post-traumatic stress after the experience of complex trauma should be
considered a separate, yet related, disorder from the well-established PTSD. Since traumatic
experiences are commonplace and often detrimental, establishing which factors contribute to risk
and resilience is of great importance. Having secure attachment to a primary caregiver and
family cohesion are consistently supported in the literature as contributors to resilience. The
primary objective of the current research was to contribute to the ongoing development and
understanding of complex trauma and the proposed C-PTSD categorization. Additionally, this
study evaluated the relationship between experiencing trauma, developing trauma
symptomology, and familial factors of (1) a positive family environment in youth and (2) secure
attachment. Results provided supportive evidence of a significant relationship between a higher
number of potentially traumatic events (PTEs) and increased trauma symptomology, specifically
PTSD and C-PTSD. A positive family environment and a more secure attachment style were
found to be associated with less PTSD and C-PTSD symptomology. This study provides
preliminary support and suggests further exploration of factors that may strengthen resilience and
protect against trauma-related symptoms would be beneficial.

ii
 Introduction

Childhood experiences of trauma are a significant public health concern in the United

States. In a general population sample of children and adolescents, Costello, Erkanli, Fairbank,

and Angold (2002) found that one in four had experienced at least one high-magnitude stressor

(such as the death of a caregiver) in their lifetime. Over half (57%) reported experiencing

additional significant life stressors. In a nationally representative sample, estimating rates of

victimization in youth aged 2 to 17 years old, only 29% had experienced no victimization,

concluding that childhood exposure to violence, crime, maltreatment, and other forms of

victimization are a “routine part of ordinary childhood in the United States” (Finkelhor, Ormrod,

Turner, & Hamby, 2005; p.18). In minority, refugee, and clinical populations, a single

experience of trauma is the exception rather than the rule (Kira, 2008) and victimized youth are

then at greater risk, as they are frequently re-victimized (Finkelhor, Ormrod, & Turner, 2007;

Herman, 1992). Childhood trauma literature suggests that an early history of maltreatment or

severe adversity significantly affects the mental health of these individuals (Briere & Jordan,

2009; Felitti et al., 1998; Rees et al., 2011).

In addition to causing a host of issues in childhood, traumatic experiences that occur

during critical developmental stages are thought to have considerable negative influence on adult

mental health (Briere & Jordan, 2009; Felitti et al., 1998; Rees et al., 2011). The Centers for

Disease Control and Prevention (CDC) reported information about adverse childhood

experiences collected from approximately 9,000 adult health maintenance organization (HMO)

members (Felitti, et al., 1998). Over 30% of participants reported being physically abused,

23.5% reported being exposed to family alcohol abuse, 19.9% reported being sexually abused,

18.8% reported experiencing mental illness in their family, 12.5% reported witnessing

1
interparental violence, 11% reported emotional abuse as a child, and almost 5% of participants

reported having experienced family drug abuse. The authors outlined relationships between these

experiences and depression, suicidality, domestic violence, alcohol and drug abuse, sexual

promiscuity and sexually transmitted diseases, as well as other serious health-related concerns in

adulthood. Further, the more cumulative and stressful the traumatic experiences, the more likely

individuals were to develop health problems later in life such as cancer, stroke, heart disease, and

diabetes.

The development of posttraumatic stress disorder (PTSD) is one of the most common

psychological sequelae of trauma in adults (Copeland, Gordon, Angold, & Costello, 2007;

Feeny, Foa, Treadwell, & March, 2004). Individuals who develop PTSD following trauma have

an even greater risk of developing life course impairments, including major depression,

substance dependence, unemployment, and marital instability (Breslau, Davis, Peterson, &

Schultz, 2000). Lifetime prevalence rate estimates for adults with PTSD range from 6.8%

(Kessler, et al., 2005) to 25% (Hidalgo & Davidson, 2000).

Individuals who experience trauma at an early age or for a prolonged period of time, or

who experience trauma of an interpersonal nature, may show symptoms that fall outside the

range covered by PTSD (van der Kolk, 2005). These symptoms often give rise to “comorbid”

diagnoses, frequently thought of and treated separately, and as unrelated to the traumatic

experience. In fact, individuals who have experienced trauma across a variety of time spans and

developmental stages have reported numerous symptoms not represented by a PTSD diagnosis.

Reported symptoms have included depression, anxiety, dissociation, substance misuse, self-

hatred, self-destructive and risk-taking behavior, difficulties with interpersonal relations

(including parenting), as well as medical and somatic concerns (Courtois, 2008). These

2
symptoms are commonly categorized as comorbid diagnoses rather than identified as meaningful

components of a complex posttraumatic adaptation.

In addition to recognizing complicated reactions, another area of importance remains the

identification of factors that promote both risk and resiliency. Family environment and secure

attachment have been identified as primary protective factors that influence resilience to trauma-

related disorders. Family unity and cohesion are associated with resilience (Liem et al., 1997;

Resnick et al, 1997). Further, children are thought to develop different patterns of attachment

organization based on their experiences with their primary caregivers (Ainsworth et al., 1978).

When these experiences are positive, and the caregiver is accessible and responsive, the social

development of the child will follow a “normal course” (Ainsworth et al.; p. 9). Attachment

styles impact the development of the internal working models applied to future relationships

(Paley, Cox, Burchinal, & Payne, 1999). They influence individuals’ beliefs regarding their own

self-worth and schemas of how others will respond to their needs. When a secure attachment

representation is developed, others are considered supportive and reliable, and self-worth

healthy. When an insecure model is established, others are believed to be unavailable, rejecting,

or inconsistently available and self-value is not as strongly developed. The influence of

attachment styles within adult relationships is an important area to consider in relation to overall

health and wellness. In Bowlby’s words (as cited in Hazan & Shaver, 1994), attachment is an

essential consideration when studying human behavior “from the cradle to the grave.”

The result of traumatic experience during developmental stages is either stronger, more

resilient individuals who are better able to successfully maneuver life experiences, or more

vulnerable, less resistant individuals who may be limited in their ability to effectively navigate

these same experiences. The comprehensive view of developmental consequences is summed up

3
by Sroufe (1997): “Disturbance is not a given; it is supported. Pathology is not something a child

‘has’; it is a pattern of adaptation reflecting the totality of the developmental context to that

point.” Those who move through traumatic experiences and manage to remain on a normal

developmental trajectory are said to have resilience.

Since traumatic experiences are commonplace and may be detrimental, establishing

which factors contribute to risk and to resilience is a topic of great importance for children, their

clinicians, their families, and the community. Although the field is vast and there are difficulties

defining a fluid construct such as resilience, research currently suggests that building resiliency

may not be the obscure and daunting task it was once thought to be (Bonanno, 2008; Masten,

2001: Yehuda, 2004). In order to protect individuals and communities from considerable mental

health difficulties, a better understanding of the complexity of trauma experiences and resulting

sequelae is imperative. The ability to accurately identify trauma-related developmental

disruptions, factors that facilitate resilience, and treatment options that appropriately address

both of these will aid in fewer long-term mental and physical health problems (Jonkman et al.,

2013; Lindauer, 2012).

Review of Literature

Posttraumatic Stress Disorder May Be Insufficient

A clinical diagnosis of posttraumatic stress disorder (PTSD) includes these criteria: (1)

exposure to a traumatic event, (2) re-experiencing the event, (3) avoidance of the trauma-related

stimuli, (4) negative thoughts or feelings related to the traumatic event, (5) prolonged

physiological hyperarousal, (6) symptom duration of longer than one month, and (7) functional

impairment due to these symptoms (American Psychiatric Association [APA], 2013). Re-

experiencing symptoms of PTSD may include disturbing, intrusive thoughts and nightmares;

4
negative thoughts and feelings may include a negative affect, feelings of isolation, and

exaggerated blame of self or others; hyperarousal may include disruptive hypervigilance and a

decrease in sleep quality.

PTSD is less frequently diagnosed in childhood than during adulthood (Feeny, et al.,

2004; Yule, 2001). A general population sample of 1,420 children (nine-, eleven-, and thirteen-

year-olds) were followed annually through sixteen years of age (Copeland, et al., 2007). Though

trauma experiences were common, clinical PTSD was rarely found in this age group. According

to the Diagnostic and Statistical Manual, 4th edition Text Revision (DSM-IV-TR; APA, 2000),

childhood symptoms may present differently than adult symptoms and may include disorganized

or agitated behavior, recurrent or distressing thoughts, repetitive play, nightmares, sleep

disturbance, and difficulties concentrating. The DSM-5 (APA, 2013) now includes updated

guidelines for a PTSD diagnosis in children less than six years of age: (1) exposure to a

traumatic event, (2) intrusive re-experiencing, (3) avoidance of trauma-related stimuli, and (4)

trauma-related physiological arousal that includes the possibility of negative behavior.

Those individuals exposed to trauma in formative periods of development are thought to

be at risk for symptoms and functional impairment well beyond a PTSD diagnosis (Ford, 2017).

Hodges et al. (2013) found that youth who experienced cumulative interpersonal trauma

developed symptom complexity rather quickly, supporting the proposed developmental trauma

disorder (DTD; van der Kolk, 2005). DTD would classify those individuals with a high number

of varying symptoms associated with repeated trauma exposure along the developmental

continuum. A DTD diagnosis continues to be debated and falls within the ongoing discussion

surrounding complex trauma and diagnoses that fit these experiences.

5
Complexity of Traumatic Experiences and Resulting Symptomology

What happens when an individual experiences complex trauma? Courtois (2008) has said

it quite simply, “complex trauma generates complex reactions” (p. 86). Van der Kolk (2005, p.2)

defines complex trauma in childhood as “the experience of multiple, chronic and prolonged,

developmentally adverse traumatic events, most often of an interpersonal nature, often within the

child’s caregiving system.” Herman (1992) found that there have been multiple independent

recommendations to expand on an insufficient PTSD diagnosis for various specific populations

dating back to Niederland’s work with Holocaust survivors in the 1960’s. Niederland concluded

that the single concept of ‘traumatic neurosis’ was insufficient for the multitude of clinical

presentations he observed. Herman (1992) also indicated that Tanay, who worked with

Holocaust survivors at about the same time, described character changes in traumatized

individuals that fell outside a typical trauma response (Krystal, 1968). When childhood and

developmental considerations enter the traumatic response equation, Gelinas (1983) spoke of

“complicated traumatic neurosis” of survivors of childhood sexual abuse. Goodwin (1988)

referred to the symptomatology of prolonged childhood abuse survivors as “severe post-

traumatic syndrome.” As noted, van der Kolk (2005) has suggested “developmental trauma

disorder,” a term that seems to encapsulate the importance of both the complexity of the

traumatic experience itself and the stage at which it occurs.

Given the complicated nature of prolonged and interpersonal traumatic experiences and

the effects of these on individuals and on society, it is not surprising that the diagnosis of

complex-posttraumatic stress disorder (C-PTSD) is also complex, and even controversial (Ford,

2017). Despite Hermann’s proposal over two decades ago, that trauma should be evaluated with

more breadth, C-PTSD does not yet exist as a diagnostic category in the standard diagnostic

6
reference for the mental health field, the Diagnostic and Statistical Manual (DSM). Though C-

PTSD had not yet been formally defined and no standardized measurement had been agreed

upon, Hermann’s appeal resulted in numerous aspects of complex trauma being evaluated by

research. There was enough consensus to warrant the proposed C-PTSD diagnosis in the newest

edition of the International Classification of Diseases (ICD-11; World Health Organization,

2019). The current diagnosis consists of six symptoms clusters that include the three PTSD

criteria of reexperiencing, avoidance, and hypervigilance and three disturbances of self-

organization (DSO) symptoms defined as emotional dysregulation, interpersonal difficulties, and

negative self-concept.

In both the American Psychiatric Association’s DSM and the World Health

Organization’s ICD, the complexity of PTSD criteria has increased through the years. “Enduring

personality change after catastrophic experience (EPCACE),” a posttraumatic syndrome, was

added to the ICD-10 (WHO, 1992) category of adult personality and behavior disorders.

EPCACE may be preceded by PTSD and must be chronic (at least two years). In addition to

PTSD symptoms, EPCACE also includes changes in beliefs about the world, self, and the future

that endure. In alignment with the ongoing categorical versus spectrum debate and discussion of

how diagnoses might be more accurately assessed and treated, the complex trauma construct has

begun to gain momentum in research. There are a number of proposed diagnoses being explored

along the trauma continuum that will likely expand our understanding of trauma-related

disorders beyond PTSD. These include: complex PTSD (C-PTSD), which labels those who have

survived prolonged, repeated, or multiple traumatic experiences (Herman, 1992); disorders of

extreme stress (DESNOS), a diagnostic category catching those that do not neatly fit the PTSD

criteria and most often indicating that the victim was in some way captive by the perpetrator of

7
the trauma (Herman, 1992); “cumulative trauma,” a term used to identify the number of

different types of interpersonal trauma an individual has experienced (Briere, Hodges, &

Godbout, 2010; Briere, Kaltman, & Green, 2008; Follette, Polusny, Bechtle, & Naugle, 1996);

continuous traumatic stress (CTS), which identifies those individuals living in realistic and

ongoing fear of continual victimization (Eagle, 2013); partial PTSD, for those meeting sub-

threshold PTSD symptoms (Friedman et al., 2011); and developmental trauma disorder (DTD;

van der Kolk, 2005), which classifies those individuals with a high number of varying symptoms

associated with repeated trauma exposure along the childhood developmental continuum. It

should be noted that complex trauma and complex PTSD are often thought to be associated with

childhood experiences. Although this relationship is certainly established in the literature, trauma

events that are sustained, repeated, or complex in nature do not only occur in childhood; hence,

‘complex trauma’ will be considered an umbrella term, under which DTD falls.

In the eleventh edition of the World Health Organization (WHO) International

Classification of Diseases (ICD-11; 2019), there are separate and distinct definitions for

posttraumatic stress disorder (PTSD) and complex PTSD (C-PTSD; Maercker et al., 2013).

Many of the symptoms that are currently associated with the C-PTSD diagnosis in the ICD-11

are included in DSM-5’s PTSD category. The difference is in how they are classified. In the

DSM-5 all symptoms are included under one umbrella category and in the ICD-11 there are two

separate, yet related, diagnoses. DSM-IV-TR included three major symptom clusters: re-

experiencing, avoidance and/or numbing, and arousal. DSM-5 has broken the avoidance and/or

numbing cluster into two distinct categories: avoidance and persistent negative alterations in

cognitions and mood. This new category, called “alterations in arousal and reactivity,” contains

most of DSM-IV-TR’s numbing symptoms and also now includes irritable or aggressive

8
behavior and reckless or self-destructive behavior as well. In the most recent DSM (DSM-5,

APA, 2013), PTSD has changed substantially in ways that are similar to the EPCACE

symptoms. Criterion A no longer requires the intense emotional reaction of fear, hopelessness, or

horror at the time of the traumatic event. Criterion D now includes negative alterations in

cognitions and mood: persistent negative beliefs about oneself, distorted blame of self or others,

and overwhelming emotional distress (i.e., anger, guilt, shame). These changes mean that

persistent difficulties with beliefs and emotions are now included as core elements of PTSD. The

hyperarousal symptom category now includes dysregulated behavior in the form of verbal or

physical aggression and self-destructive behavior.

Further, a new PTSD subtype was added to DSM-5 that is characterized by hypo-arousal

and dissociative depersonalization or derealization symptoms. PTSD no longer falls in the

anxiety disorder category and is placed in a new section of trauma and stressor-related disorders.

As proposed, PTSD will continue to result from symptoms related to the experience of trauma

(re-experiencing, avoidance, and hyperarousal). The ICD-11 C-PTSD diagnosis requires that an

individual meet all criteria for PTSD and additional symptoms related to disturbances in self-

organization: (1) affective dysregulation, (2) a negative sense of self and identity, and (3)

difficulty in interpersonal relatedness (Hyland, 2017; Marinova & Maercker, 2015; WHO, 2019).

These categories propose to cover the array of difficulties experienced by those who have

undergone sustained, repeated, or complex trauma (Cloitre et al., 2015). DSM-5 also added

special criterion for those with dissociative symptoms or delayed expression of symptoms and

included verbiage for developmental considerations in youth. Again, it is noted that youth

symptomology may present differently than adult symptoms and often manifests in behavior.

9
 The ICD-11 C-PTSD diagnosis does not specify particular traumatic experiences that are

required to result in the C-PTSD diagnosis. However, it does suggest that repeated or prolonged

traumas, from which escape is difficult or impossible are commonly associated with this

diagnosis (Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; Maercker et al., 2013; WHO,

2019). Identifying the most appropriate method of evaluating and measuring the complexity of

potentially traumatic events (PTEs) is a challenging task. Identifying frequency has been the

most commonly used method of determining severity of PTEs (Tolin & Foa, 2006). Whether this

is an adequate measure of complexity is debated. Cumulative trauma has been operationalized as

the number of different types of interpersonal trauma experienced (Briere, Hodges, & Godbout,

2010; Cloitre et al.). This count has been shown to be a robust predictor of negative psychosocial

outcomes (Cloitre et al., 2009). However, there is disagreement about which is the best way to

account for symptom complexity – whether counting individual trauma types, experiences of

trauma regardless of type, or some combination of these two variables being the best method is

yet to be determined (Briere et al, 2008; Cloitre et al.).

Cloitre et al. (2015) argue that the effects of exposure to trauma are heterogeneous and

that the current PTSD diagnosis and related available treatments do not adequately address this

heterogeneity. Increases in trauma complexity (measured as number of types of trauma

exposure) are associated with an increase in number of symptoms that occur beyond those found

in PTSD (Cloitre et al., 2008; Briere, Kaltman, & Green, 2008; Karam et al., 2014). Commonly,

these include emotional dysregulation, difficulties with interpersonal relations, substance misuse,

anger, dissociation, and suicidality (Cloitre et al.). Complex trauma experiences both in

adulthood and during childhood predict symptom complexity; however, cumulative trauma

experiences during childhood developmental stages were found to be stronger contributors to

10
symptomology (Cloitre et al., 2009). Complex psychological trauma interferes with individual

adaptive growth, adversely affects numerous biopsychosocial outcomes, and interferes with

development of resilience (D’Andrea et al., 2012). Traumas identified as complex may include:

violence that occurs within relationships where the individual should be able to expect safety and

protection; sexual, physical, or emotional abuse and neglect of a youth; betrayal of caregiver or

authority trust; and intentional violation of physical boundaries and integrity. Ford (2017) links

these different forms of trauma with four descriptors: intentional, interpersonal, inescapable, and

creating insecurity. Complex psychological trauma is identified by a violation of social compacts

and moral principles of beneficence, dignity, autonomy, and justice (Ford, 2017). Whether these

are the crucial aspects of traumatic experiences in determining outcomes is yet to be agreed

upon.

Hyland (2017) sought to contribute construct validity to this diagnosis and to assess

whether gender, trauma history, and psychological risk factors (anxiety and dysthymia) distinctly

identified PTSD from C-PTSD-specific disturbances in self-organization (DSO). Being female

and the number of instances of sexual abuse experienced in childhood showed greater effects on

PTSD symptoms than on DSO symptoms. Higher levels of anxiety were more predictive of

PTSD symptoms, where higher levels of dysthymia were strongly predictive of DSO symptoms.

These results are consistent with the ICD-11 conceptualization of C-PTSD.

There is a growing body of evidence that supports the construct validity of C-PTSD as a

distinct diagnosis (Hyland, 2017). According to Cloitre et al. (2015), six studies have shown

support for the ICD-11 formulation of PTSD and C-PTSD. Cloitre, Garvert, Brewin, Bryant, and

Maercker (2013) evaluated those who had experienced a range of interpersonal violence, while

Elklit, Hyland, and Shevlin (2014) looked at rape victims, domestic violence victims, and those

11
who had experienced traumatic bereavement. Community samples of both young adults

(Perkonigg, Hofler, Wittchen, Trautmann, & Maercker, 2015) and veterans (Wolf et al., 2015),

as well as a population of institutional abuse victims (e.g., foster care, religious organizations;

Knefel, Garvert, Cloitre, & Lueger-Schuster, 2015) have shown support. Preliminary data from a

clinical sample of trauma-exposed youth also found distinct PTSD and C-PTSD categories

(Stolbach, Garvert, & Cloitre, 2014). Further, analyses indicate that C-PTSD is more frequently

found among those who have suffered complex trauma histories and is correlated with more

severe symptomology (Cloitre et al., 2013).

There has also been disagreement surrounding the definitions of individual variables

included in the C-PTSD discussion. Some researchers have indicated that C-PTSD lacks

discriminant validity because there is a great deal of overlap between PTSD and C-PTSD

(Bryant, 2012). Cloitre et al. (2011) argues that the overlap is part of the definition and that C-

PTSD is a complex variation of PTSD. Bryant (2012) further justifies the construct by arguing

that while emotional dysregulation is in some way part of every diagnostic category, that it is the

requirement of emotional dysregulation that distinguishes C-PTSD from PTSD and other

diagnoses.

Factors That May Promote Resilience

In addition to causing a host of issues in childhood, exposure to trauma during

developmental years may considerably and negatively impact the more vulnerable individual

well into adulthood (Briere & Jordan, 2009; Felitti et al., 1998; Rees et al., 2011). Since

traumatic experiences are commonplace and often detrimental, establishing which factors

contribute to risk and resiliency is of great importance. “By examining the processes that

contribute to positive adaptation in situations that more typically result in maladaptation, we

12
should be better able to devise ways of promoting positive outcomes in high-risk children and

youth” (Werner, 1993).

As Sroufe (1997) suggested, disturbance and pathology are developmental patterns of

adapting. Those who move through traumatic experiences and manage to remain on a normal

developmental trajectory are said to have resilience. In less favorable outcomes, negative

consequences may include pathological developments. How we think about these outcomes

drives what we do about them. Research now suggests that though resilience most certainly

exists in a complex system, building resilience is much easier, less elusive, and a far more

ordinary process than once believed (Bonanno, 2008; Masten, 2001; Yehuda, 2004).

Researchers typically categorize the building blocks of resiliency into three primary

groups: individual, familial, and community factors (Luthar et al., 2000; Punamäki, Qouta,

Miller, & El-Sarraj, 2011; Rutter, 1999; Werner, 2000). Individual protective factors may

include such strengths as an internal locus of control, the use of flexible coping strategies, an

easy temperament, higher intelligence, a positive self-concept, and sociability (Werner, 2000).

Dispositions are often thought to have a strong genetic base; however, they may certainly be

supported or thwarted by family and community influence (i.e., genotype-environment effects;

Scarr & McCartney, 1983). Familial protective factors may include a developed secure

attachment, well-adjusted and competent caregivers, low birth order, a small family size, and

strong religious beliefs (Werner & Smith, 1992). While the individual exists within the context

of family, the family also functions within the larger context of community. Protective factors in

this category may include close friendships, a positive educational environment and experience,

as well as positive role models (e.g., teachers; Luthar et al., 2000). The familial factors of a

13
positive family environment in youth and a securely developed attachment are the primary focus

of the current study.

Family Environment as a Protective Factor

Primary protective factors that fall within the family context and are consistently

supported in the current literature include: parents who are physically and psychologically

healthy, parental support, and family cohesion. Childhood is the period of time during which

self-regulation, self-soothing, identity formation, and the ability to be in relationship with others

is developed (Cook et al., 2005; Kinniburgh, Blaustein, Spinazzola, & van der Kolk, 2005). Not

only do caregiving relationships during this stage of development form the foundation for youth

representation of self, but also of others, and, of how to interact with their community at large

(Cook et al., 2005). When the environment is negative, the child has little support, and traumatic

experiences are commonplace, development is greatly hindered (McCormack & Thomson,

2017). Maltreatment negatively influences secure attachment and other biological systems meant

to aid affect, behavior, and cognition throughout developmental stages (Cook et al., 2005;

Kinniburgh, et al., 2005). Further, McCormack and Thomson (2017) suggest that impaired

emotional, intellectual, and psychosocial development may prevent these individuals from later

seeking treatment and contribute to misdiagnoses in adulthood.

Punamäki et al. (2011) analyzed the prevalence of resilience within a sample of 640

Palestinian children and adolescents living in conditions of armed conflict and military

occupation on the Gaza Strip. The resilient children had psychologically healthy parents, who

were supportive and practiced fewer punishing methods of parenting. Literature on resilience

generally suggests that parents who are able to regulate their own emotions are more likely able

to provide a safe family environment, despite potentially traumatic events. These parents are

14
successful in comforting their children and providing hope and safety, even in the terrifying

circumstances of war.

One of the most powerful supports for young children in the face of trauma is a positive

relationship with a primary caregiver (e.g., secure attachment; Scheeringa & Zeanah, 2001;

Zeanah, Boris, & Larrieu, 1997). Parenting quality may include structure, warmth, and

expectations. Maternal avoidance and insensitive responses to a child’s traumatic experiences

have been strongly related to less positive outcomes in young children (Deblinger, Steer, &

Lipmann, 1999; Laor et al., 1997; Scheeringa & Zeanah, 2001). Punamäki et al. (2011) suggest

that family support, as a protective factor, crosses cultural boundaries; all children benefit from

this positive and powerful foundational experience.

Not only in various cultures, but also with various types of trauma and health risks,

family unity and cohesion have been found to have associations with resilience. In a study of

adult survivors of childhood sexual abuse, individuals categorized as having resilience were

more likely to have experienced a less stressful family environment, fewer family disruptions

(e.g., death, divorce), and more stable and cohesive family relations (Liem et al., 1997). Further,

in the National Longitudinal Study on Adolescent Health, 12,118, seventh- through twelfth-grade

adolescents were interviewed to identify risk and protective factors in relation to their emotional

health, violence, substance use, and sexuality (Resnick et al., 1997). Parent and family

connectedness was found to be a primary protective factor in relation to almost every health risk

behavior studied, with the exception of teenage pregnancy. As previously reported, a primary

focus of the current study is the familial factor of a positive family environment in youth.

Parenting quality and the strength of the parent-child relationship has also consistently

been found to contribute to social competence (Masten et al., 1999). Further, positive role-

15
models and a safe and stable environment encourage children’s social competence and their

pursuit of additional skills (Brown, Kallivayalil, Mendelsohn, & Harvey, 2012). All individuals

showing resilience in the Kauai Longitudinal Study reported at least one person in their life that

provided unconditional support (Werner, 2000). Developmental psychopathology currently

emphasizes the “ordinary magic” of resilience (Masten, 2001, p. 227). Human growth and

adaptation normally include processes that strengthen it. However ordinary, these processes are

vulnerable to assaults from potentially traumatic events, which disrupt healthy regulation.

“Dysfunction cannot be fully understood without a deeper understanding of health and

resilience” (Bonanno, 2008, p.110). Although it is difficult to quantify “normal,” much resilience

research suggests that recovery from stress and traumatic experiences indicate mental health and

resilience is the more typical path. In reviewing the state of resilience research to date, Luthar et

al., (2000) suggest that it is yet too early to merge the concepts of “resilience” and “positive

adjustment.” However, as research continues to identify and refine protective and risk factors

along developmental pathways, we may find less need to focus on and refine the construct of

resilience itself and simply understand that there are unlimited points along an individual’s

trajectory where positive supports may be beneficial.

Secure Attachment as a Protective Factor

In the 1940’s, John Bowlby developed a theory of human protection and survival that is still

widely researched and supported. Since that time, its application and implications have continued

to be expanded upon in the literature (Bretherton, 1992). Bowlby’s attachment theory (1951)

described a set of innate behaviors of humans, mainly focused in infancy and childhood, which

operate to establish proximity to caregivers in order to assure protection from danger. This

attachment behavioral system incorporates evolutionary, social, behavioral, emotional, and

16
biological aspects that interact in order to accomplish three main functions of an attachment

relationship: proximity maintenance, a feeling of having a safe haven, and establishing a secure

base (Hazan & Shaver, 1994).

Mary Ainsworth’s observations of infant-mother attachment relationships and contributions

to the theory began in 1953 (Bretherton, 1992). Ainsworth, Blehar, Waters, and Wall (1978)

described the attachment system as a set of stable behaviors that are concerned with

reproduction, care, and protection of young. A child’s attachment behavior focuses on achieving

and maintaining close proximity to other people. It is developmentally typical that by the child’s

sixth or seventh month of life, these behaviors are primarily directed toward one person, the

primary caregiver (Ainsworth et al., 1978; Hazan & Shaver, 1994). Complementary behavior

that has the same protection and survival function is activated in the caregiver (Ainsworth et al.).

When the caregiver is supportive and caring in response, the child is able to achieve a state of felt

security that then allows the activation and use of other behavioral systems (Hazan & Shaver). A

caregiver’s inconsistent, unavailable, and unreliable responses result in the child experiencing a

sense of insecurity.

Bowlby (1969; 1973) and Ainsworth et al. (1978) explained that the role of affect and

emotion within the attachment system is to evaluate, appraise, and interpret environmental

conditions, both consciously and unconsciously. Advantageous to an individual’s survival is the

ability to respond to dangerous situations automatically and to recognize certain danger cues

without having to learn them. Bowlby (1973) indicated that humans’ innate danger cues include:

unusual or strange situations, sudden changes in environment, being alone, and having others

rapidly approach. The emotional appraisal of these cues then activates the attachment system,

causing behavior meant to bring the caregiver close. When more than one danger cue is present,

17
or when a person is tired or ill (Feeney & Collins, 2001), the individual is likely to respond with

particularly strong reactions.

Interference with the primary goal of proximity is likely to result in anxiety and protest.

Emotional reactions meant to bring a caregiver close are predictable and most often occur in a

particular sequence (Hazan & Shaver, 1994). Protest occurs first, which may include crying,

searching, and resistance to comfort from anyone other than the primary caregiver. If these

actions do not bring the caregiver closer, despair, passivity, and sadness are likely to follow, with

emotional detachment being the final stage if the child’s attempts result in failure. Bowlby

regarded these responses as highly adaptive (Hazan & Shaver). Other signaling behavior of

human infants and children includes calling, smiling, and when the child is old enough, crawling

or walking toward the caregiver on his own (Ainsworth et al., 1978).

The critical aspect of proximity is not just the simple presence of the caregiver, but their

availability and responsiveness, even when separation occurs (Ainsworth et al., 1978). When a

child develops a sense of security in the caregiver’s reliability, attachment behavior decreases

and is less likely to occur with short periods of separation. Ainsworth et al. refer to this low level

of attachment behavior activation as “using the mother as a secure base from which to explore”

(p. 22). Additional factors that may contribute to a child’s attachment security include his or her

own temperament and the sensitivity of the caregiver’s responsiveness (Hazan & Shaver, 1994;

Pederson & Moran, 1999). When a child is able to use the primary caregiver as a secure base, he

is able to engage in non-attachment behaviors that include exploration.

If a child experiences positive separation from and reunion with his caregiver, these

experiences help him to build a positive internal working model of his attachment figure

(Ainsworth et al., 1978). This representational model allows the attachment bond to be

18
maintained while the child is able to accept longer periods of absence without serious distress.

Although these inner representations cannot replace proximity or contact with the caregiver,

much research is based on the presumption that they are carried into adulthood and influence

relationships throughout the lifespan (Roisman, Madsen, Henninghausen, Sroufe, & Collins,

2001).

Narrowly defining Bowlby’s theory to include only the physical proximity of child and

caregiver or their attachment interactions would be a misinterpretation of his work (Ainsworth et

al., 1978). In defense of broadly defining and applying attachment theory, Pederson and Moran

(1999) explain that the attachment system could also function to establish a stable relationship in

which to develop social skills. The authors interpret Bowlby’s statements that attachment

functions include comfort and assistance as support for expanding on the theory’s

conceptualization of child and caregiver relations. They argue that the socialization process of

the human child during its lengthy period of dependency would confer survival and reproductive

advantage.

Childhood Attachment

Children are thought to develop different patterns of attachment organization based on their

experiences with their primary caregivers (Ainsworth et al., 1978). When these experiences are

positive, and the caregiver is accessible and responsive, the social development of the child will

follow a “normal course” (Ainsworth et al.; p. 9). In their recommendation to use attachment

theory as an organizational framework for research on other important close relationships, Hazan

and Shaver (1994) boil the attachment system conclusion down to a single question: “Can I

count on my attachment figure to be available and responsive when needed?” (p. 5). The authors

indicate that there are three possible answers to this question: yes, no, and maybe.

19
 These patterns of caregiver behavior lead to three primary attachment organization styles in

the child (Hazan & Shaver, 1994). Where the caregiver is consistently available and responsive,

the child’s attachment style is said to be secure. When the caregiver is consistently unavailable

and unresponsive, the attachment style is considered anxious/avoidant. Inconsistent caregiver

responses result in the child’s anxious/ambivalent attachment. An additional category of

disorganized/disoriented has been recognized when one pattern cannot be specifically identified

or the child’s attachment has become confused due to caregiver pathology or interruptions in

caregiving relationships.

These attachment styles affect the development of the internal working models applied to

future relationships (Paley, Cox, Burchinal, & Payne, 1999). They influence individuals’ beliefs

regarding their own self-worth and schemas of how others will respond to their needs. As would

be expected, if a secure representation is developed, others are considered supportive and

reliable. Self-worth is high. When an insecure model develops, others are expected to be

unavailable, rejecting, or inconsistently available and self-worth is low. Although more research

is needed in this area, the impact of attachment styles within various aspects of adult

relationships is a diverse and growing field of research. Attachment as a construct has continued

to broaden since its inception and has grown to include different types of social relationships and

numerous aspects within them (Pederson & Moran, 1999).

Adult Attachment

The impact of early attachment relationships and the resulting internal working models

have been shown to influence an individual’s functioning in close relationships and across the

lifespan (Barry & Lawrence, 2013; Paley et al., 1999). Furthermore, overall romantic

relationship fulfillment is thought to be greatly dependent on satisfaction within the category of

20
safety and security needs (Hazan & Shaver, 1994). For these reasons, attachment theory provides

a useful framework for researching and understanding social relationship processes, experiences,

and well-being.

According to attachment theory, the central function of close relationships is to provide

comfort, care, support, and intimacy to those in the relationship (Barry & Lawrence, 2013).

These needs become more salient during times of illness, stress, or danger. For the human

animal, close relationships are of utmost importance and one of the primary indicators of

psychological health and well-being throughout all life stages (Hazan & Shaver, 1994). Parents,

or other primary caregivers, are our first social relationships. While their position as primary

attachment relations and models for our first internal representations of relationship are not

typically given up completely, their roles shift to more peer-like as we become adults (Hazan &

Shaver). Romantic relationships often take their place in meeting primary attachment needs.

The expansion of attachment theory to adulthood and extended social relationships allows

for the exploration of the processes that motivate humans to establish and sustain attachment

bonds with significant others. Within these reciprocal relationships, research indicates that

meaning and experience can be effectively evaluated within the attachment framework

(Birnbaum et al., 2006). Makinen and Johnson (2006) refer to the attachment bond as, “an active,

affectionate, reciprocal relationship in which partners mutually derive and provide closeness,

comfort, and security” (p. 1055). Adults typically rely primarily on their romantic partner as their

main, and often most important, source of comfort and care (Feeney & Collins, 2001). Even in

these most important and intimate relations, where individuals feel willing and able to express

their innermost thoughts and feelings, “expression of inner states” (p. 515) need to be monitored

and regulated to some degree in order to maintain equilibrium within the relationship (Ben-

21
Naim, Hirschberger, Ein-Dor, & Mikulincer, 2013). Intimate and close relations result in

heightened emotional responses, sensitivity, and vulnerability. In adult romantic relationships,

much like in caregiver-child relationships, Hazan and Shaver’s (1994) bottom line attachment

question becomes, “Can I trust my partner to be available and responsive to my needs?” (p. 13).

Possible answers continue to be yes, no, and maybe.

Current research suggests that a two-dimensional model is ideal when conceptualizing

attachment; the two dimensions being anxiety and avoidance (Brennan, Clark, & Shaver, 1998:

Fraley & Waller, 1998). Attachment anxiety is characterized by patterns of intensive effort in

seeking close proximity, as well as hypersensitivity and focused attention around relational

nuances. Attachment avoidance is characterized by generally evading close relational proximity,

as well as denial of attachment needs and vulnerability (Mikulincer & Florian, 1998). Lower

levels of both dimensions are indicative of more secure and healthier attachment (Schachner,

Shaver, & Mikulincer, 2005). Attachment styles are believed to remain relatively stable as

developed in childhood, into and through adulthood (Bowlby, 1988). There are, of course,

instances when this is not the case (e.g., earned security), however, generally speaking, adult

attachment orientations can be thought of as “chronic interpersonal styles” (Feeney & Collins,

2001, p. 973) reflecting patterns of expectations, emotions, and behaviors regarding the self and

relationships with others (Birnbaum, Reis, Mikulincer, Gillath, & Orpaz, 2006).

One of the most widely used and well-validated self-report measures of adult attachment, the

Experiences in Close Relationships-Revised scale (ECR-R; Fraley, Waller, & Brennan 2000),

measures individuals on two subscales of attachment: avoidance and anxiety. The measure

provides an average score for both attachment-related avoidance and for anxiety. In general,

22
avoidant individuals find discomfort with intimacy and seek independence, while anxious

individuals tend to fear rejection and abandonment (Fraley, Waller, & Brennan, 2000).

A Note on Categorical versus Dimensional Measurement of Attachment

As in diagnostic conceptualization, there is a fair amount of controversy regarding the best

way to measure attachment concepts: categorically or dimensionally. Categorical coding is

typically seen as the gold standard in the field (Roisman et al., 2007). However, the four

attachment orientations are achieved by measuring adults’ placement on the two fundamental

dimensions of anxiety and avoidance (Feeney & Collins, 2001). Securely attached adults are low

on both the anxiety and the avoidance dimensions. Insecurely attached adults are high on either

the anxiety or avoidance dimensions, or both. Dismissing (avoidant) individuals are low in

anxiety and high in avoidance. Those who are fearfully avoidant report high anxiety and high

avoidance. Finally, preoccupied (anxious) adults are high in anxiety and low in avoidance.

Researchers working to use dimensional models argue that statistical power and precision of

measurement are compromised when cut-points are arbitrarily determined (Roisman et al.,

2007). Furthermore, categorical measurement may lead to the underestimate of attachment

stability longitudinally. Roisman et al. argue that the differentiations made by the well-known

and frequently used Adult Attachment Interview match more closely with a dimensional model

and that using the anxiety and avoidance dimensions may offer a better understanding of

attachment security than the categorizations that are currently used. The authors suggest that the

same research questions could be addressed with increased statistical power and greater insight,

strengthening the research base relating to attachment.

23
A Note on Continuous-Secure versus Earned-Secure Attachment

Yet another topic of disagreement that is found within the attachment literature is the

usefulness of identifying continuous-secure versus earned-secure categories. Continuous-secure

individuals convey a generally positive state of mind regarding positive experiences throughout

their childhood (Paley et al., 1999). Earned-secure individuals communicate stories of difficult

childhoods in a generally positive and realistic way that indicates they are not likely controlled

by these experiences. Although Paley et al. indicate differences regarding the two divisions of

secure attachment, results of their study on marital functioning indicated that current state of

mind regarding childhood experiences was more likely related to future relationship problems

than the experiences themselves. This does not support the need for a distinction. Furthermore,

Roisman, Fortuna, and Holland (2006) conducted a study that manipulated mood in order to

compare earned and continuous attachment security. Their results indicated that categorization of

earned-secure versus continuous-secure was altered with a simple mood induction exercise,

while categorization of the over-arching categories of secure versus insecure was not. While this

distinction is an interesting consideration, it is currently unclear whether it is useful. More

research is needed.

Current Project

The purpose of the current research is to contribute knowledge regarding the experiences

of potentially traumatic events (PTEs), as well as factors that may insulate against complex

trauma symptomology. While it is generally accepted that a positive family environment in youth

and a securely developed attachment style contribute to resilience and are considered protective

factors, the literature has not yet evaluated these factors in relation to complex trauma

experiences and the development of C-PTSD. Therefore, this study aims to provide unique

24
information regarding the potentially moderating effects of a positive family environment in

youth and a securely developed attachment style on the relationship between PTEs and the

occurrence of complex trauma symptoms.

Further, C-PTSD is currently being considered a separate, yet related, disorder from the

well-established PTSD. The most recent research has supported a distinct display of symptoms

for those individuals who have experienced prolonged and interpersonal violence (e.g.,

childhood abuse, domestic violence, being a prisoner of war). Using the ICD-11 models of PTSD

and C-PTSD will be associated with differing profiles of those individuals who endorse

symptoms. Current review suggests that the ICD-11 model, using the ITQ measure, has only

begun to be evaluated and has not yet been used in a college sample. The current study

evaluating this categorization will also contribute knowledge to the growing literature on

complex trauma.

Youth with trauma histories are a difficult population with whom to conduct research due

to their dependent status, reliance on caregivers or other family members, their hesitancy to

report on illegal or unsafe traumatic experiences, and their overall ‘vulnerable’ status (Campbell,

Greeson, & Fehler-Cabral, 2014; McDonald, 2015). As such, an undergraduate college sample is

seemingly the ideal sample to query; the majority being near the end of their childhood

development, they are more likely of an age young enough to be competent reporters of recent

experiences and relations, yet less dependent on caregivers and therefore more likely to report on

negative traumas that may have occurred in or related to the family framework.

The hypotheses of the current study were as follows:

The primary objective of the current study is to contribute additional understanding to the

ongoing development and knowledge of complex trauma and resulting C-PTSD symptomology,

25
as well as to evaluate whether the factors of family environment and attachment account for

significant variability in relationship to trauma symptoms.

The current study uses a non-clinical sample of college students in order to determine

qualitatively different groups or classes of participants, using the only self-report symptom scale

currently available that is designed to measure C-PTSD classification as defined by the ICD-11

(International Trauma Questionnaire for ICD-11; ITQ; Cloitre, Roberts, Bisson, & Brewin,

2014). While identifying trauma symptoms in a non-clinical college population sample, this

study will contribute to the ongoing evaluation of the three-tier classification of the International

Trauma Questionnaire (ITQ). Research has demonstrated that participants would belong in one

of three categories that include (a) those with low or no symptom endorsement, (b) those who

endorse symptoms indicating they meet criteria for PTSD, and (c) those who endorse symptoms

indicating they meet criteria for C-PTSD. Because this is a community sample and not a clinical

population, it was important to assess the degree to which the population has clinical symptoms.

Those individuals who are thought to have built resilience have been identified by

research to be resistant to the development of mental health diagnoses (D’Andrea et al., 2012;

Sroufe, 1997). As described above, factors that contribute to the development of resilience

include individual, familial, and community factors (Luthar et al., 2000; Punamäki, Qouta,

Miller, & El-Sarraj, 2011; Rutter, 1999; Werner, 2000). The current study investigated whether

participants who reported having (1) a more positive family environment in youth and (2) secure

attachment were less likely related to those who developed trauma symptomology, and more

specifically C-PTSD symptomology.

26
 Specifically, it was predicted that:

1. Trauma Symptomology:

a. There is a relationship between number of PTEs an individual has experienced, as

reported on the Childhood Trauma Questionnaire (CTQ) and the Life Events

Checklist for DSM-5 (LEC-5), and their ITQ-determined group belonging (non-

clinical, PTSD, and C-PTSD).

2. Family Environment:

a. There is a relationship between an individual’s family environment experience

and their trauma symptomology categorization. Participant’s reported scores on

the Family Environment Scale (FES) will result in and discriminate between three

distinct categorizations of participants: a non-clinical, a PTSD, and a C-PTSD

group.

3. Attachment:

a. There is a relationship between an individual’s attachment anxiety and PTSD

categorization. Individuals’ higher scores on the anxiety dimension of attachment,

as measured by the ECR-R, will be significantly associated with categorization of

PTSD symptomology, as indicated by the ITQ.

b. There is a relationship between an individual’s attachment avoidance and C-

PTSD categorization. Individuals’ higher scores on the avoidance dimension of

attachment, as measured by the ECR-R, will be significantly associated with

categorization of C-PTSD symptomology.

c. There is a relationship between an individual’s overall attachment style and their

trauma symptomology categorization. Participant’s reported scores on the

27
 Experiences in Close Relationships – Revised (ECR-R) will result in significant

variation between three distinct categorizations of participants: a non-clinical, a

PTSD, and a C-PTSD group.

4. Potentially Protective Factors in Relation to Trauma Experiences:

a. Factors of (1) a more positive family environment, as indicated by scores on five

relational subscales of the Family Environment Scale (FES), and (2) more secure

attachment, as indicated by lower scores on the Experiences in Close

Relationships-Revised (ECR-R) anxiety and avoidance dimensions, will account

for significant variance variability in group belonging (non-clinical, PTSD, and C-

PTSD) when participants’ PTE experiences are controlled.

Method

Participants

Participants are undergraduate students enrolled at The University of Montana during the

Fall 2018 and Spring 2019 semesters, who participated voluntarily for research credit in their

psychology or related courses. As expected, the study sample was predominantly freshman and

sophomore; there was no exclusion criteria for age or class standing. Current research into

various aspects of complex trauma has primarily evaluated participants seeking or participating

in treatment, or those known to have experienced trauma. This study aims to contribute to the

data by analyzing a non-clinical community sample of college undergraduates attending a mid-

sized northwestern public university and by evaluating an individual’s experience of a positive

family environment in youth and a securely developed attachment style as potentially protective

factors in relation to C-PTSD symptomology. Further, current research does not include using

the ITQ with a non-clinical sample.

28
 A total of 469 college students participated in the study. Data from 30 respondents was

discarded due to excessive missing data (more than 10%). In addition, 13.5% of participants had

one or more missing data points (but missing less than 5%) for one or more of the assessment

measures. Missing data points on individual measures were replaced with respondents’ mean

scores, based on completed items from that particular scale. Power analyses (Faul, Erdfelder,

Buchner, & Lang, 2009) conducted prior to data collection revealed a sample size of 336 would

provide sufficient power for the purposes of this study. Certain statistical analyses used in the

current project required a higher number of participants in analyzed groupings. Adjustments

were made to the analyses and are specifically addressed in those sections. Participants in the

remaining sample (n = 439) ranged in age from 18 to 66 years old (mean age = 21.90 years, SD

= 6.48). The majority reported freshman class standing (46.7%), with a minority sophomore

(21.6%), junior (15.9%), senior (14.1%), and graduate (0.2%). Six participants (1.4%) were

unsure of their class standing. Participants consisted predominantly of persons who identified as

White/Non-Hispanic (84.1%). Respondents also identified as belonging to two or more races

(5%), being Native American/Alaska Native (3.9%), Hispanic (3%), Asian/Pacific Islander

(2.7%), and Black (1.1%). More than 90% of participants reported having an adult attachment

figure who loved and supported them, and with whom they felt close. The majority of

respondents identified their mother or step-mother as that person (37%). Participants also

identified their father or step-father (30%) or both parents (12%) as primary attachment figures.

Analyses were performed to determine whether composition of participants’ ITQ

classification of group belonging (non-clinical, PTSD, and C-PTSD) differed demographically.

When comparing participants’ group belonging (non-clinical, PTSD, and C-PTSD), groups did

not differ significantly in age F(2) = 0.762, p > .05, class standing F(2) = 2.659, p > .05, or

29
racial/ethnic composition F(2) = .616, p > .05. There were significant differences between the

groups in whether or not they reported having a primary attachment figure F(2) = 0.494, p =

.000; this relationship will be evaluated further. Demographic information on participants is

reported in Table 1.

Measures

Clinician-administered interviews and self-report instruments are both integral pieces of

assessment, diagnoses, and treatment. However, for the purpose of the current study, self-report

surveys were administered in consideration of both time and expense. Further, it has been

reported that individuals may be more comfortable and therefore more forthcoming, when

responding to a questionnaire than to another individual (Nader, 2008). All self-report measures

were administered via the university’s web-based portal.

Demographic information. A demographic questionnaire was developed for this study

(see Appendix B). Participants were asked to provide their age, class standing, ethnicity, current

marital/relationship status, and history of an important attachment relationship.

Potentially traumatic events. In an effort to obtain the most accurate information

regarding the relationship between complex trauma and potentially traumatic events (PTEs)

experienced by participants, these events were measured by both a childhood and a lifetime

experience measure. Further, as explained previously, cumulative trauma has been most

commonly operationalized as the number of different types of interpersonal trauma an individual

has experienced (Briere, Hodges, & Godbout, 2010; Cloitre et al.). PTEs will be measured by

adding the total number of distinct types of traumatic experiences from the following two

measures. Table 2 provides information on PTEs.

30
 Table 1

Demographic Information of sample

______________________________________________________________________________

Variable Total Sample Non-Clinical PTSD C-PTSD

______________________________________________________________________________

Age 21.90 21.81 21.00 22.77

(mean +/-SD) +/- 6.48 +/- 6.30 +/- 7.45 +/- 7.18

Ethnicity (%)
White 84 82 4.9 13.1

Black/African American 1.1 80 0 20

Hispanic/Latino 3.0 92.3 0 7.7

Asian / Pacific Islander 2.7 83.3 16.7 0

American Indian / Alaska
3.9 41.2 11.8 47.1
Native
Bi-cultural /
5.0 90.9 4.5 4.5
Multi-cultural
Other / Unspecified 0.2 100 0 0

Class Standing
Freshman 46.7 80 5.9 14.1

Sophomore 21.6 76.8 8.4 14.7

Junior 15.9 78.6 4.3 17.1

Senior 14.1 93.5 0 6.5

______________________________________________________________________________

Note. Mean age and standard deviation of total sample and participants by ITQ-categorized trauma group

belonging. Percentage of total sample and participants by ITQ-categorized trauma group belonging.

______________________________________________________________________________

31
 The Childhood Trauma Questionnaire (CTQ: Bernstein and Fink, 1997; see Appendix C)

is a 28-item self-report questionnaire that measures exposure to a range of abuse experiences

specific to childhood. The CTQ includes five subscales: Emotional Abuse, Physical Abuse,

Sexual Abuse, Emotional Neglect, and Physical Neglect. Participants are asked to report their

experiences “growing up as a child and as a teenager” within five domains using a 5-point scale

ranging from 1 (never true) to 5 (very often true) regarding the frequency the event was

experienced. Bernstein and Fink also provide interpretive guidelines to allow the identification of

likely cases of abuse and neglect for three levels of severity: low, moderate, and severe.

Bernstein et al. (2003) utilized four samples (clinical and nonclinical, N = 1978) to examine

internal consistency/reliability and found the following coefficient alpha ranges: .84-.89 for

emotional abuse, .81 to .86 for physical abuse, .92 to .95 for sexual abuse, .85 to .91 for

emotional neglect, and .61 to .78 for physical neglect. In addition, Bernstein et al. provided

results suggesting good validity, as evidenced by the measurement invariance of the scale across

four diverse populations, as well as the criterion-related validity of corroborative data between

therapists’ ratings of abuse and neglect and participants’ responses. The CTQ also has three

items that assess minimization/denial in order to detect possible under-reporting of traumatic

events. Cronbach’s Alpha for the current study was .90.

The Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013; see Appendix D) is

a 17-item self-report measure designed to assess for exposure to potentially traumatic events

(PTEs) in a participants’ lifetime. The events referenced in the LEC-5 do not include childhood

abuse or neglect, but do include other traumatic events that may have occurred during childhood.

The measure prompts participants to rate their exposure to 16 events known to potentially result

in traumatic stress, including natural disaster, fire/explosion, accident, exposure to toxic

32
substance, sexual assault, combat, captivity, illness/injury/human suffering, violent or accidental

death, and/or harm caused by respondent. One additional item assesses exposure to “Any other

very stressful event or experience,” which is used to capture experiences not listed. Participants

respond to each item (e.g., Serious accident at work, home, or during recreational activity), by

selecting one of six responses: “happened to me”, “witnessed it”, “learned about it”, “part of my

job”, “not sure”, and “does not apply.” The LEC-5 is a recent revision of the Life Events

Checklist for DSM-IV (Gray, Litz, Hsu, & Lombardo, 2004). Psychometric characteristics for

the LEC-5 are not yet available. Because there are minimal changes between the versions, LEC-5

psychometric characteristics are expected to be similar to those demonstrated by the LEC

(Weathers et al., 2013). The LEC has demonstrated strong convergence with measures of

psychopathology that are known to be associated with trauma exposure. Changes to the new

measure include addition of the “Part of my job” response option, and a wording change to one

of the items. The LEC does not produce a total score, rather it yields a total number of PTEs

experienced by direct exposure to self or others.

Potentially protective factors. The current study evaluated both the experience of a

positive family environment in youth and a securely developed attachment style as potentially

protective factors in the development of trauma symptomology, and more specifically the

development of C-PTSD, after exposure to PTEs.

Attachment. Adult attachment was measured using the Experiences in Close

Relationships-Revised scale (ECR-R; Brennan, Clark, & Shaver, 1998; Fraley, Waller, &

Brennan, 2000; see Appendix E). The ECR-R is a 36-item self-report measure containing two

dimensional subscales: attachment anxiety (defined as discomfort with relational closeness and

depending on others; 18 items) and attachment avoidance (fear of rejection and abandonment; 18

33
items). Participants are asked to indicate the extent to which they agree with each item on a 7-

point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree) and to respond

regarding how they feel in emotionally intimate relationships (i.e., how they “generally

experience relationships”). A third attachment variable was created by plotting the intersection of

the anxiety and avoidance dimensions on a four-quadrant graph resulting in an attachment style

categorization: (1) secure, (2) pre-occupied, (3) fearful-avoidant, or (4) dismissing-avoidant.

Studies completed by Sibley, Fischer, and Liu (2005) demonstrated high internal

reliability (α=.93 for attachment anxiety and α=.94 for attachment avoidance), high test-retest

reliability over a 3-week period (r=.90 for attachment anxiety and r=.92 for attachment

avoidance), and an accurate fit for the hypothesized two-factor solution as examined through

confirmatory factor analysis. In addition, the ECR-R demonstrated good validity, as measured by

its association with interaction diary ratings by subjects, as well as the scales’ moderate

correlations with another attachment questionnaire (Relationship Questionnaire; Bartholomew &

Horowitz, 1991; see Sibley et al., 2005). Cronbach’s Alpha for the current study was .95.

Family Environment. The Family Environment Scale (FES; Moos & Moos, 1981; see

Appendix F) is a 90-item, True-False, self-report questionnaire with ten subscales designed to

measure the social and environmental characteristics of a family. The FES is useful for

understanding how family members perceive the family and how each member’s behavior

affects the family unit during a time of crisis or transition. For the current study, participants

were asked to respond to items in relation to their family of origin. There are three versions of

the FES: the ‘Real Form,’ which measures participants’ perceptions of their family environment;

the ‘Ideal Form,’ which measures how participants would conceptualize the ideal family

environment; and the ‘Expectations Form,’ which measures participants’ expectations of what

34
their future family will be like. For the purposes of the current research, only the ‘Real Form’

was used.

Scores load on three primary scales that include the Relationship, System Maintenance,

and Personal Growth Scales. The Relationship Scale is comprised of three subscales: (1)

expressiveness, (2) conflict, and (3) cohesion. Items include questions about the extent of help,

support, and commitment family members have for one another. These scales also assess the

degree that family members are able to express their feelings directly, act openly, and openly

express aggression, conflict, and anger within the family environment. The System Maintenance

Scale is comprised of two subscales: (4) control and (5) organization. These subscales measure

clear organization and structure in family planning and the degree to which set rules and

procedures are used by the family. The Personal Growth Scale includes: (6) achievement

orientation; (7) active-recreational orientation; (8) moral-religious emphasis; (9) intellectual-

cultural orientation; and the (10) independence subscales all assess the Personal Growth

dimensions. The degree that members of the family are self-sufficient, assertive, and make their

own decisions is assessed by these subscales, as is the extent that activities are placed into a

competitive or achievement-oriented framework; the degree of family interest in social, political,

cultural, and intellectual activities; the degree of importance placed on religious and ethical

issues; and the degree of involvement in recreational and social activities. According to the

authors, the Relationship and System Maintenance dimensions primarily reflect internal

functioning and the Personal Growth dimension primarily reflects relations between the family

and social or community contexts. For this reason, and for the purposes of this study, only the

five subscales of the Relationship and System Maintenance dimensions will be evaluated: (1)

Cohesion, (2) Expressiveness, (3) Conflict, (4) Organization, and (5) Control.

35
Table 2

Percentage of Participants Who Reported Potentially Traumatic Events in the Total Sample and

Categorized by ITQ-determined Group-Belonging

______________________________________________________________________________

Potentially % of. Non-Clinical PTSD C-PTSD

Traumatic Event N Total Sample % of Total % of Total % of Total

Childhood

Emotional Abuse 46 10.5 65.2 6.5 28.3

Physical Abuse 26 5.9 61.5 11.5 26.9

Sexual Abuse 44 10 61.4 2.3 36.4

Emotional Neglect 13 3 53.8 7.7 38.5

Physical Neglect 19 4.3 47.4 10.5 42.1

CTQ Endorsed Events

None 347 79 85.6 4.9 9.5
One 53 12.1 73.6 7.5 18.9
Two 29 6.6 55.2 0 44.8
Three 4 0.9 50 50 0
Four 5 1.1 60 0 40
Five 1 0.2 0 0 100
Lifetime

Natural Disaster 130 29.6 80 3.8 16.2

Fire / Explosion 101 23 75.2 7.9 16.8

Transportation
274 62.4 81.1 5.6 13.3
Accident
Serious Accident 144 32.8 79.7 7.7 12.6
Toxic Substance
39 8.9 64.1 10.3 25.6
Exposure

36
 Physical Assault 170 38.7 75.9 5.3 18.8

Assault with Weapon 56 12.8 67.9 7.5 24.5

Sexual Assault 105 23.9 66 7.8 26.2

Other Unwanted
166 37.8 76.2 5.5 18.3
Sexual Experience
Exposure to War 32 7.3 60.9 8.7 30.4

Captivity 13 3 46.2 0 53.8

Life-threatening Illness 183 41.7 80.1 4.5 15.3

Severe Human
71 16.2 69 8.5 22.5
Suffering
Violent Death 78 17.8 69.2 7.7 23.1

Unexpected Death 268 61 78.1 3.5 18.4

Harm You Caused 23 5.2 69.6 13 17.4

Other 75 17.1 76 5.2 18.8

______________________________________________________________________________

Note. Sample sizes and percentage of populations listed were determined by hand categorizing seventy-

nine participants who had reported traumatic experiences in the other category. Percentages of PTEs

categorized by ITQ group belonging were determined by SPSS with other category as self-reported.

37
 The answer sheet used to score the questionnaire is arranged so that each column of

responses comprises an FES subscale. The subscale raw scores of each participant are

determined by summing the number of responses provided in each column. The total raw score

was determined by summing the total number of responses across the columns. Raw scores were

converted to standard scores using tables found in the FES Manual.

The FES normative sample for the ‘Real Form’ subscales was based on 1,125 non-

distressed and 500 distressed families. When compared to non-distressed families, distressed

families were lower on cohesion and expressiveness and higher on conflict and control (Moos &

Moos, 1981). For each of the five relevant FES subscales, Cronbach’s alpha fell within an

acceptable range (varying from a high of .78 for the cohesion subscale, to a low of .67 for the

control subscale), indicating an adequate amount of internal consistency for the subscales. Test-

retest reliability for all subscales was calculated using data from 47 individuals who responded to

the ‘Real Form’ twice, with an eight-week interval between pre- and post-test responses. Test-

retest reliability was found to be within an acceptable range, varying from a low of .73 for the

expressiveness subscale to a high of .86 for the cohesion subscale. Cronbach’s Alpha for the

current study ranged from a modest low of .62 for the cohesion subscale to a high of .82 for the

conflict subscale (expressiveness = .65, organization = .72, and control = .73).

Psychological symptomology. The International Trauma Questionnaire (ITQ; Cloitre, Roberts,

Bisson, & Brewin, 2017; Appendix G) is a self-report measure that was developed for the

assessment of ICD-11 PTSD and C-PTSD diagnoses. The ITQ results in a three-tier

classification that identifies participants’ group belonging in one of three categories that include

(1) those with low or no symptom endorsement (i.e., non-clinical), (2) those who endorse

symptoms indicating they meet criteria for PTSD, and (3) those who endorse symptoms

38
indicating they meet criteria for C-PTSD. As mentioned previously, there is overlap in these

diagnostic categorizations; C-PTSD is a complex variation of PTSD. However, specific

emotional dysregulation distinguishes C-PTSD from PTSD. The ITQ categorization of group

belonging was used throughout the analyses of this study.

Previously referred to as the ICD-11 Trauma Questionnaire (ICD-TQ), the ITQ is a 20-

item self-report measure with nine PTSD and nine Disturbances in Self-Organization (DSO)

items. Three items are used to measure Re-experiencing (RE; items P1–P3), two items to

measure avoidance (AV; items P4–P5), and two items to measure Sense of Threat (Th; items P6–

P7). CPTSD includes PTSD as well as three clusters reflecting disturbances in self-organization

(DSO). Nine items represent the three DSO clusters of Affective Dysregulation (AD; items C1–

C2), Negative Self-Concept (NSC; items C3–C4), and Disturbances in Relationships (DR; items

C5–C6). Symptom endorsement is scored on a Likert scale, indicating how much a symptom has

been bothersome in the past month, with scores ranging from 0 (not at all) to 4 (extremely). The

PTSD items are answered in response to the question ‘how much have you been bothered by that

problem for the past month?’ and the DSO items are answered in terms of how one ‘typically

feels, thinks about themselves, or relates to others.’ A diagnosis of PTSD requires that: (i) an

individual has experienced a traumatic event, (ii) indicates the presence of at least one symptom

in each of its three clusters (as indicated by a score of ≥ 2 on the Likert scale – ‘Moderately’),

and (iii) indicates functional impairment associated with these symptoms. A diagnosis of C-

PTSD requires that: (i) PTSD criteria are met, (ii) indicates the presence of at least one symptom

in each of the three DSO clusters (as indicated by a score of ≥ 2 on the Likert scale –

‘Moderately’), and (iii) indicates functional impairment associated with these symptoms.

39
 In an evaluation of this measure and its distinct symptom profiles, Karatzias et al. (2017)

found evidence to support the measure. Reported Cronbach’s alpha was high for the DSO

indicators (AD = .79, NSC = .91, and DR = .83) and was modest for the PTSD indicators (RE =

.55, AV = .63, and Th = .78). Cronbach’s Alpha for the current study was high for both the DSO

indicators (AD = .60, NSC = .88, and DR = .80) and the PTSD indicators (RE = .80, AV = .78,

and Th = .78).

Procedure

This study was conducted in accordance with the code of conduct of the American

Psychological Association and was submitted for approval from the Institutional Review Board

of the University of Montana prior to data collection. A description of the survey was posted on

an online psychology research board and participants completed an online anonymous survey.

When participants entered the online survey site, they were presented with a study description

that explained their participation and explicitly stated they were free to elect not to complete the

survey or to skip any question. The study description also included contact information for the

University of Montana’s Counseling Services in the event they wished to talk regarding any

stress due to study participation (see Appendix A). After completing the survey, participants

were directed to a separate website where they received extra credit for their participation;

however, their identity was not linked to the data.

Descriptive Statistics and Preliminary Analyses

Data from a total of 439 participants with acceptable levels of data was evaluated and is

reported on in the current study. Internal consistency was calculated for all the measures and, as

reported in the Method section, all alphas were found to be acceptable. All statistical analyses

40
were carried out with IBM’s Statistical Package for the Social Sciences (SPSS) for Mac, version

25 and the R Project for Statistical Computing.

Results

Psychological symptomology

The International Trauma Questionnaire (ITQ; Cloitre, Roberts, Bisson, & Brewin, 2017)

categorized participants into three groups based on trauma symptomology: (1) non-clinical (n =

357), (2) meeting criteria for PTSD (n = 23), and (3) meeting criteria for C-PTSD (n = 59). The

current C-PTSD diagnosis consists of six symptoms clusters that include the three PTSD criteria

of reexperiencing, avoidance, and hypervigilance and an additional three symptoms of disturbed

self-organization (DSO), including emotional dysregulation, interpersonal difficulties, and

negative self-concept.

These group categorizations were used in each of the following hypotheses. A priori

power analyses for proposed statistical methods indicated that overall, 336 participants were

needed and between 59-168 were needed per ITQ-determined group belonging for adequate

power. Although total sample size (N = 439) was sufficient, group belonging did not have

adequate sample size. Despite being under-powered, this study resulted in numerous significant

findings.

Experiences of Potentially Traumatic Events

Participants reported childhood abuse experience through the CTQ (Bernstein & Fink,

1997), which measures emotional, physical, and sexual abuse, as well as emotional and physical

neglect. Bernstein and Fink offer guidelines for classifying varying abuse and neglect

experiences into four categories: (1) none to minimal, (2) low to moderate, (3) moderate to

severe, and (4) severe to extreme. For the purpose of this study, participants were dichotomized

41
into two groups for each of the five categories of abuse and neglect. For each category,

participants with scores in the none to moderate range were classified as not having endorsed

that PTE. Participants in the moderate to extreme range were classified as having endorsed that

PTE. The majority of respondents (79%) reported no childhood abuse/neglect experiences. Of

those who did experience abuse/neglect in childhood, emotional abuse was the most commonly

endorsed (10.5%). Ten percent endorsed sexual abuse, 5.9% endorsed physical abuse, 4.3%

endorsed physical neglect, and 3% reported experiences of emotional neglect.

Participants reported other lifetime potentially traumatic events (PTEs) on the Life

Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013). This measure did not include

childhood abuse. Every category of PTE listed on the LEC-5 was endorsed. The most commonly

experienced event was having been in a transportation accident (62.4%), the sudden and

unexpected death of someone close (61%), and a life-threatening illness or injury (41.7%). A

significant number of participants also reported an experience of physical assault (38.7%), and

unwanted or uncomfortable sexual experience (37.8%), and a serious work or recreational

accident (32.8%). Other categories frequently endorsed included having experienced a natural

disaster (29.6%), a sexual assault (23.5%), and a fire or explosion (23%).

When comparing potentially traumatic events in the overall sample, the Native American

population stands out. While making up only 3.9% of the total sample size, Native Americans

represented almost 12% of those who endorsed symptom criteria for PTSD and 47% of those

who endorsed C-PTSD symptomology. This is a salient illustration of the increased vulnerability

and serious health inequities within this population.

In order to examine lifetime reports of participants’ PTEs, scores for both the CTQ and

the LEC-5 were combined to obtain a total number of potential traumatic events experienced.

42
When these reports were totaled, only 6.6% of respondents had not experienced PTEs in their

lifetime. The most common number of PTEs experienced were two or three (12.3%,

respectively), with 11.8% of participants endorsing five PTEs, 11.2% endorsing four PTEs,

10.7% endorsing one, 10.3% endorsing six, 6.8% endorsing seven, and 5.7% endorsing eight

PTEs. Just over 12% of participants endorsed nine or more PTEs. See Table 2 for specific

information on PTEs.

Briere et al. (2008) warn that cumulative trauma and symptom complexity variables are

unlikely to be normally distributed, recommending that statistical analyses used to evaluate this

data is resistant to normality violations. Hayes and Rockwood (2017) debunk this as “myth” and

indicate that centering independent and dependent variables will not affect interaction tests, but

simply change the metric of measurement. Because there are conflicting ideas on how normalcy

of data distribution influences results in relation to trauma, this assumption was given particular

consideration. Non-parametric models were used to evaluate data that violated normality

assumptions.

Hypothesis 1: There is a relationship between number of PTEs an individual has

experienced, as reported on the Childhood Trauma Questionnaire (CTQ) and the Life

Events Checklist for DSM-5 (LEC-5), and their ITQ-determined group belonging (non-

clinical, PTSD, and C-PTSD).

Due to the fact that the dependent variable is a positive integer that fits the Poisson

distribution, Poisson regression was used to test this association. Two separate regressions were

conducted due to complications resulting from combining childhood and lifetime experiences

(i.e., total number of PTEs). Thus, the dependent variables in these analyses were the number of

PTEs experienced by participants (1) related to abuse in childhood and (2) all other traumatic

43
events throughout their lifetime. The independent variables were participants’ group belonging

(0 = non-clinical, 1 = PTSD, 2 = C-PTSD).

Both the likelihood ratio chi-square test (χ2 = 39.719, DF = 2, p < .0001) and the

deviance-based goodness of fit (D = 460.4361, DF = 436, D/DF = 1.06) indicated that the full

model using the CTQ childhood PTEs measure was a significant improvement in fit over a null

model (i.e., no predictors). Though belonging to the PTSD group was not a significant predictor

of the number of experienced PTEs, the incidence rate ratio (1.744) indicated that for those in the

PTSD group, the incidence rate for childhood PTEs was 1.74 times greater than that for the non-

clinical group. In other words, the incidence rate for those with PTSD was 74.4% greater than

that for the non-clinical group. Belonging to the C-PTSD group was a significant predictor of the

number of experienced PTEs (b = 1.203, S.E. = .1779, p < .0001). The incidence rate ratio

(3.331) indicated that for those in the C-PTSD group, the incidence rate for childhood PTEs was

3.33 times greater than that for the non-clinical group. In other words, the incidence rate for

those with C-PTSD was 233% greater than that for the non-clinical group.

Although the likelihood ratio chi-square test (χ2 = 38.796, DF = 2, p < .0001) indicated

that the full model using the LEC lifetime PTEs measure was a significant improvement in fit

over a null model (i.e., no predictors), the deviance-based goodness of fit (D = 982.892, DF =

436, D/DF = 2.254) did not. The deviance-based test provided a better result because it indicated

how well outcomes met assumptions that the outcome is a positive integer, and that the mean and

variance of the outcome are equal.

Belonging to the PTSD group was not a significant predictor of the number of

experienced PTEs (b = 0.185, S.E. = .0972, p = .057). The incidence rate ratio (1.203) indicated

that for those in the PTSD group, the incidence rate for lifetime PTEs was 1.203 times greater

44
than that for the non-clinical group. In other words, the incidence rate for those with PTSD was

only 20.3% greater than that for the non-clinical group. Belonging to the C-PTSD group was

found to be a significant predictor of the number of experienced PTEs (b = 0.376, S.E. = .0592, p

< .0001). Further, the incidence rate ratio (1.456) indicated that for those in the C-PTSD group,

the incidence rate for lifetime PTEs was 1.456 times greater than that for the non-clinical group.

In other words, the incidence rate for those with C-PTSD was 45.6% greater than that for the

non-clinical group. PTEs in relation to trauma are reported in Table 3.

Family Environment

Hypothesis 2: A more positive family environment, as reported on the FES, will result in

less trauma symptomology, as reported on the ITQ: non-clinical, PTSD, and C-PTSD.

In order to evaluate this relationship, it was proposed that five separate between-subjects

one-way analyses of variance (ANOVAs) would be conducted. While meeting criteria for the

assumption of homogeneity of variance, all collected FES subscale data distributions violated

assumptions of normality. For this reason, the Kruskal-Wallis H test for non-parametric data was

used instead. The dependent variables in these analyses were participants’ scores on the five FES

subscales (cohesion, expressiveness, conflict, organization, control), and the independent

variable was participants’ ITQ group belonging (0 = non-clinical, 1 = PTSD, 2 = C-PTSD). FES

subscales were examined for multicollinearity and found to be independent; tolerance scores

ranged between 0.524 – 0.790 and VIF scores ranged between 1.27 – 1.91. Family environment

subscales information is reported in Table 4.

45
Table 3

Potentially Traumatic Events in Relation to Trauma Symptomology

____________________________________________________________________________________________________________

Childhood Trauma B SE Wald Sig Exp(B) 95% C.I.

Intercept -1.389 0.1060 171.734 .000 0.249 -1.597 -1.181

C-PTSD 1.203 0.1779 45.763** .000 3.331 0.855 1.552

PTSD 0.556 0.3335 2.781 .095 1.744 -0.097 1.210

Lifetime Trauma

Intercept 1.416 0.0261 2949.279 .000 4.120 3.915 4.336

PTSD 0.376 0.0592 40.296** .000 1.456 1.297 1.635

C-PTSD 0.185 0.0972 3.611 .057 1.203 0.994 1.455

___________________________________________________________________________________________________________

Note. Hypothesis 1. Potentially traumatic event (childhood, lifetime) variables evaluating variance in relation to group belonging (non-

clinical, trauma symptomology).

** p < .01.

___________________________________________________________________________________________________________

46
Cohesion Subscale

Cohesion subscale scores met criteria for homogeneity of variance according to Levene’s

test, F(2,436) = .212, p = .809. However, Shapiro-Wilk’s (W(439) = .914, p < .000) indicated

that data were not normally distributed. A Kruskal-Wallis H test showed that there was a

statistically significant difference among the three ITQ group belonging categorizations on FES

cohesion subscale scores, H (2) = 7.428, p = .024. The family cohesion mean rank was 224.93

for the non-clinical sample, 245.26 for those who met criteria for PTSD, and 180.32 for those

who met criteria for C-PTSD. Dunn’s pairwise tests with Bonferroni corrections were conducted

to make post hoc comparisons. The participants in the C-PTSD group (M = 37.64, SD = 14.77)

scored significantly lower than the non-clinical group (M = 42.66, SD = 13.79). There was no

evidence of a significant difference between other groups. Effect size was small (!2 = 0.017).

Expressiveness Subscale

Expressiveness subscale scores met criteria for homogeneity of variance according to

Levene’s test, F(2,436) = .109, p = .897. However, Shapiro-Wilk’s (W(439) = .956, p < .000)

indicated that data were not normally distributed. A Kruskal-Wallis H test showed that there was

a statistically significant difference among the three ITQ group belonging categorizations on FES

expressiveness subscale scores, H (2) = 20.157, p < .000. The family expressiveness mean rank

for the non-clinical sample was 231.99, 204.85 for those who met criteria for PTSD, and 153.34

for those who met criteria for C-PTSD. Dunn’s pairwise tests with Bonferroni corrections were

conducted to make post hoc comparisons. The participants in the C-PTSD group (M = 40.34, SD

= 13.77) scored significantly lower than the non-clinical group (M = 49.18, SD = 13.58). There

was no evidence of a significant difference between other groups. Effect size was small (!2 =

0.046).

47
Table 4

Family Environment Subscales

______________________________________________________________________________

Family Factor M SD H(2) p ε2

______________________________________________________________________________

Cohesion 42.10 13.98 7.428* .024 .017

Expressiveness 47.84 13.91 20.157** .000 .046

Conflict 52.79 14.21 24.513** .000 .056

Organization 48.50 12.60 1.689 .430 -

Control 51.64 13.40 6.727* .035 .015

______________________________________________________________________________

Note. Hypothesis 2. Family Environment Scale subscale means, standard deviations, and

statistics used to compare group belonging.

*p < .05. ** p < .01.

______________________________________________________________________________

48
Conflict Subscale

Conflict subscale scores met criteria for homogeneity of variance according to Levene’s

test, F(2,436) = .796, p = .452. However, Shapiro-Wilk’s (W(439) = .930, p < .000) indicated

that data were not normally distributed. A Kruskal-Wallis H test showed that there was a

statistically significant difference among the three ITQ group belonging categorizations on FES

conflict subscale scores, H (2) = 24.513, p < .000. The family conflict mean rank score was

207.44 for the non-clinical sample, 222.20 for those who met criteria for PTSD, and 295.12 for

those who met criteria for C-PTSD. Dunn’s pairwise tests with Bonferroni corrections were

conducted to make post hoc comparisons. The participants in the C-PTSD group (M = 61.29, SD

= 12.93) scored significantly higher than the non-clinical group (M = 51.36, SD = 13.90). There

was no evidence of a significant difference between other groups. Effect size was small (!2 =

0.056).

Organization Subscale

Organization subscale scores met criteria for homogeneity of variance according to

Levene’s test, F(2,436) = .622, p = .537. However, Shapiro-Wilk’s (W(439) = .957, p < .000)

indicated that data were not normally distributed. A Kruskal-Wallis H test showed that there was

not a statistically significant difference among the three ITQ group belonging categorizations on

FES Organization subscale scores, H (2) = 1.689, p = .430. The family organization mean rank

was 223.52 for the non-clinical sample, 214.48 for those who met criteria for PTSD, and 200.84

for those who met criteria for C-PTSD.

Control Subscale

Control subscale scores met criteria for homogeneity of variance according to Levene’s

test, F(2,436) = .155, p = .856. However, Shapiro-Wilk’s (W(439) = .958, p < .000) indicated

49
that data were not normally distributed. A Kruskal-Wallis H test showed that there was a

statistically significant difference among the three ITQ group belonging categorizations on FES

Control subscale scores, H (2) = 6.727, p = .035. The family conflict mean rank was 214.24 for

the non-clinical sample, 281.93 for those who met criteria for PTSD, and 230.70 for those who

met criteria for C-PTSD. Dunn’s pairwise tests with Bonferroni corrections were conducted to

make post hoc comparisons. Participants in the PTSD group (M = 58.17, SD = 12.55) scored

significantly higher than the non-clinical group (M = 51.01, SD = 13.37). There was no evidence

of a significant difference between other groups. Effect size was small (!2 = 0.015).

Attachment

Hypothesis 3: There is a relationship between an individual’s attachment, as reported on

the ECR-R, and their ITQ trauma symptomology categorizations: non-clinical, PTSD, and

C-PTSD.

As will be reported individually, ECR-R anxiety and avoidance subscale data

distributions met criteria for the assumption of homogeneity of variance, while violating

assumptions of normality. In order to test predicted results, Mann-Whitney U tests (New

Procedure) were conducted. It was also decided to explore these relationships further. For this

reason, the Kruskal-Wallis H test for non-parametric data was also used. The dependent

variables in these analyses were participants’ scores on the dimensional attachment subscale, and

the independent variable was participants’ ITQ group belonging (binary categorization for

Mann-Whitney U tests; 0 = non-clinical, 1 = PTSD, 2 = C-PTSD). ECR-R subscales were

examined for multicollinearity and found to be independent (Tolerance = 1.00, VIF = 1.00).

Attachment anxiety and avoidance statistical tests are provided in Table 5.

50
 Table 5

Attachment Anxiety and Avoidance

______________________________________________________________________________
Attachment
Dimension M SD U/H df / n p ε2 / η 2
______________________________________________________________________________
Anxiety –
3.43 1.25
Non-Clinical
Anxiety –
3.78 1.10
PTSD
Anxiety –
4.50 1.30
C-PTSD
Mann-Whitney U 3361 380 .145 -

Kruskal-Wallis H 31.932** 2 .000 .079

Avoidance –
3.01 1.17
Non-clinical
Avoidance –
3.15 1.02
PTSD
Avoidance –
3.61 1.17
C-PTSD
Mann-Whitney U 7412** 416 .000 .031

Kruskal-Wallis H 13.819** 2 .001 .030

______________________________________________________________________________

Note. Hypotheses 3A and 3B. Experiences in Close Relationships – Revised (ECR-R) attachment

anxiety and avoidance statistics used to compare group belonging.

** p < .01.

______________________________________________________________________________

51
Hypothesis 3a: PTSD symptomology will be associated with higher scores on the anxiety

dimension of attachment, as measured by the ECR-R.

As previously reported, research has shown that higher levels of anxiety may be more

predictive of PTSD symptoms when compared with those of C-PTSD (Hyland, 2017). While

ECR-R anxiety scores met criteria for homogeneity of variance according to Levene’s test,

F(1,378) = 2.762, p = .097, Shapiro-Wilk’s, W(380) = .981, p < .000, indicated that data were not

normally distributed. In order to determine if the PTSD group had experienced less secure

attachment, as measured by higher mean ranks on attachment anxiety, than the non-clinical

group, a Mann-Whitney U test was conducted. The dependent variable was participants’ scores

on the anxiety dimension of the ECR-R. The independent variable was participants’ group

belonging (0 = non-clinical, 1 = PTSD). The shapes of the distributions of attachment anxiety

mean ranks for both the PTSD group and non-clinical group were similar. Results, (N = 380) U =

3361, Z = -1.458, p = .145, indicate that the participants in the PTSD group (Mean Rank =

222.87) did not have significantly different mean ranks on the ECR-R anxiety subscale than non-

clinical participants (Mean Rank = 188.41).

The ECR-R anxiety subscale was evaluated beyond the hypotheses in order to identify

other significant relationships with group belonging. A Kruskal-Wallis H test showed that there

was a statistically significant difference among the three ITQ group belonging categorizations on

the ECR-R anxiety subscale scores, H (2) = 31.932, p < .0001. The ECR-R anxiety mean rank

was 204.66 for the non-clinical sample, 242.00 for those who met criteria for PTSD, and 304.25

for those who met criteria for C-PTSD. Dunn’s pairwise tests with Bonferroni corrections were

conducted to make post hoc comparisons. The participants in the C-PTSD group (Mean Score =

4.50, SD = 1.30) were ranked significantly higher than the non-clinical group (Mean Score =

52
3.43, SD = 1.25). There was no evidence of a significant difference between other groups. Effect

size was small (!2 = 0.079).

Hypothesis 3b: C-PTSD symptomology will be associated with higher scores on the

avoidance dimension of attachment, as measured by the ECR-R.

Levene’s test, F(1,414) = .012, p = .912 indicated that data met criteria for homogeneity

of variance. Shapiro-Wilk’s (W(416) = .978, p < .000) confirmed that data were not normally

distributed. In order to determine if the C-PTSD group had experienced less secure attachment,

as measured by higher scores on the avoidance dimension of the ECR-R, than the non-clinical

group, a Mann-Whitney U test was conducted. The dependent variable was participants’ scores

on the avoidance dimension of the ECR-R. The independent variable was participants’ group

belonging (0 = non-clinical, 1 = C-PTSD). The shapes of the distributions for attachment

avoidance scores of both the C-PTSD group and the non-clinical group differed. Results, (N =

416) U = 7412, Z = -3.647, p = .000, indicate that the participants in the C-PTSD group (Mean

Rank = 261.37) had significantly different mean ranks on the ECR-R avoidance subscale than

non-clinical participants (Mean Rank = 199.76). Effect size was small (η2 = 0.031).

The ECR-R avoidance subscale was evaluated further in order to identify other

significant relationships with group belonging. A Kruskal-Wallis H test showed that there was a

statistically significant difference among the three ITQ group belonging categorizations on the

ECR-R anxiety subscale scores, H (2) = 13.819, p = .001. The ECR-R avoidance mean rank was

209.91 for the non-clinical sample, 234.54 for those who met criteria for PTSD, and 275.41 for

those who met criteria for C-PTSD. Dunn’s pairwise tests with Bonferroni corrections were

conducted to make post hoc comparisons. The participants in the C-PTSD group (Mean Score =

3.61, SD = 1.17) scored significantly higher than the non-clinical group (Mean Score = 3.01, SD

53
= 1.17). There was no evidence of a significant difference between other groups. Effect size was

small (ε2 = .030).

Hypothesis 3c: Overall attachment scores on the ECR-R, which combines the anxiety and

avoidance dimensions to create an ordinal quadrant score, will result in three distinct

categorizations of participants: a non-clinical, a PTSD, and a C-PTSD group.

In order to determine if there was a difference between these groups, a Cochran-Mantel-

Haenszel (CMH) test, using the ‘row mean scores differ’ statistic, with three degrees of freedom

was used. The CMH test determined if the distribution of data in the attachment groups was the

same or different than the ITQ-determined grouped belonging distribution. When the null

hypothesis is rejected, it indicates that there is a disproportionate distribution of participants in

one or more of the two groups. A significant association between group belonging and

attachment groups was found (χ2 = 36.501, DF = 3, p <0.0001). When compared to both those

who were non-clinical and those with PTSD, there was a smaller proportion of participants with

C-PTSD in the securely attached group (1) and a higher proportion in the pre-occupied (3) and

fearfully avoidant (4) attachment groups. Further, proportionately almost half of the study

participants (46%) were both non-clinical and securely attached. The distribution of participants

across the four ECR-R groups was approximately the same for the non-clinical and the PTSD

groups. Attachment overall categorization statistic is provided in Table 6.

Although the categorization portion of this analysis was conducted as a way to contribute

additional information to the dimensional aspects of attachment measured in this study, it is

worth noting that the attachment measure used here did not allow for a category of disorganized

attachment. Disorganized attachment has been recognized when one pattern cannot be

specifically identified or the individual’s attachment has become confused due to pathology or

54
interruptions in caregiving relationships. The ability to account of these individuals in regard to

attachment style may significantly change the distribution of participants across group belonging.

Potentially Protective Factors in Relation to Trauma Symptomology

Hypothesis 4: Protective factors of (1) a more positive family environment and (2) a more

secure attachment will account for significant variability in the relationship between

experiencing trauma and symptomology categorization.

In order to explore relationships between the experience of a positive family environment

and secure attachment, the number of experienced PTEs, and trauma symptomology, a logistic

regression was conducted. It was originally proposed that this relationship would be evaluated

with moderation analyses; however, due to a lower sample size than anticipated, it was

determined that a binomial logistic regression would identify relationships between the data

more clearly. In this analysis, the PTSD and C-PTSD groups were combined in order to provide

appropriate power. Therefore, the dependent variable of the regression was participants’ ITQ

group belonging (binary; 0 = non-clinical, 1 = PTSD and C-PTSD combined). Independent

variables of the regression model included: (1) participants’ experienced PTEs, measured as

individual CTQ and LEC scores; (2) participants’ reported family environment, measured as FES

subscale scores (previously determined significant relationships; cohesion, expressiveness,

conflict, and control); and (3) participants’ attachment, measured as ECR-R avoidance and

anxiety dimensions. The logistic regression model was found to be a good fit, explaining 23%

(Nagelkerke R2) of the variance in trauma symptomology and correctly classifying 84.1% of the

cases. Results were statistically significant (χ2 = 68.373, DF = 8, p < 0.0001). Family cohesion,

expressiveness, and conflict, as well as attachment anxiety, and childhood trauma exposure were

each found to have significant relationships with reported trauma symptomology. There was no

55
evidence of significant relationships between family control, attachment avoidance, or lifetime

number of trauma exposure types and trauma symptomology.

A one unit increase in an individual’s family cohesion score was associated with 1.05

times greater odds of having a clinically significant trauma symptomology (95% CI = 1.02 –

1.07). Although increased scores on family cohesion were associated with an increased

probability of belonging in the trauma symptomology group (χ2 = 12.14, DF = 1, p < 0.0001), the

increase in probability was quite small. Essentially, family cohesion has very little effect on the

overall outcome.

Family expressiveness was the only protective variable significantly associated with

decreased odds of clinically significant trauma symptomology. A one unit increase in an

individual’s family expressiveness score was associated with 0.969 times decreased odds of

having clinically significant trauma symptomology (95% CI = .95 - .99). Decreased scores on

family expressiveness were associated with an increased likelihood of clinically significant

trauma symptomology (χ2 = 6.50, DF = 1, p = .011). Again, the decrease in probability and the

effect of family expressiveness on the overall outcome is very small.

Increased scores on family conflict were associated with an increased likelihood of

clinically significant trauma symptomology (χ2 = 4.51, DF = 1, p = .034). A one unit increase in

an individual’s family conflict score was associated with 1.03 times greater odds of having

clinically significant trauma symptomology (95% CI = 1.00 – 1.05). As with cohesion and

expressiveness, the increase in probability and the effect of family conflict on the overall

outcome is very small.

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Table 6

Attachment Categorization Comparison

______________________________________________________________________________

ECR-R
Attachment Non-Clinical PTSD CPTSD
Quadrants

Secure 200 10 9
Dismissing Avoidant 26 3 8
Pre-Occupied 95 9 26
Fearful Avoidant 35 2 16
______________________________________________________________________________

Note. Hypothesis 3C. Cochran-Mantel-Haenszel (CMH) ‘row mean scores differ’ statistic

evaluation of the Experiences in Close Relationships – Revised (ECR-R) measured attachment

categorization, created by crossing dimensional anxiety and avoidance scores on a four-quadrant

graph.

______________________________________________________________________________

57
 A one unit increase in an individual’s attachment anxiety score was associated with 1.65

times greater odds of having clinically significant trauma symptomology (95% CI = 1.29 - 2.12).

Increased scores on attachment anxiety were associated with an increased likelihood of clinically

significant trauma symptomology (χ2 = 15.566, DF = 1, p < .0001). An individual with a one unit

increase in attachment anxiety had a 65% greater probability of meeting criteria for trauma

symptomology.

A one unit increase in an individual’s childhood trauma exposure was associated with

1.73 times greater odds of having clinically significant trauma symptomology (95% CI = 1.21 –

2.47). Increased scores on childhood trauma exposure were associated with an increased

likelihood of clinically significant trauma symptomology (χ2 = 8.89, DF = 1, p = .003). For each

additional childhood trauma type an individual experienced, that individual had a 73% higher

probability of meeting criteria for trauma symptomology. Logistic regression results for

protective factors in relation to trauma are provided in Table 7.

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Table 7

Protective Factors in Relation to Trauma Symptomology

___________________________________________________________________________________________________________

Variable B SE Wald Sig Exp(B) 95% C.I.

Childhood Trauma 0.546 0.183 8.886** .003 1.726 1.206 2.472

Lifetime Trauma 0.080 0.045 3.171 .075 1.083 0.992 1.183

Family Cohesion 0.045 0.013 12.143** .000 1.046 1.020 1.073

Family
-0.032 0.012 6.504** .011 0.969 0.946 0.993
Expressiveness
Family Conflict 0.025 0.012 4.506* .034 1.025 1.002 1.049

Family Control -0.010 0.012 0.743 .389 0.990 0.967 1.013

Attachment Anxiety 0.501 0.127 15.566** .000 1.650 1.287 2.116

Attachment Avoidance 0.100 0.128 0.616 .433 1.106 0.860 1.421

___________________________________________________________________________________________________________

Note. Hypothesis 4. Potentially traumatic events (childhood, lifetime), family environment (cohesion, expressiveness, conflict,

control), and attachment (anxiety, avoidance) variables in relation to group belonging (non-clinical, trauma symptomology).

*p < .05. ** p < .01.

___________________________________________________________________________________________________________

59
 Discussion

The purpose of the current study was to examine relationships between family

environment and attachment factors that may have a protective relationship with potentially

traumatic events, and self-reported clinical categorization related to trauma. In this study,

traumatic experiences in both childhood (addressed primarily as childhood abuse) and

throughout one’s lifetime were considered in relation to traumatic symptomology. Not

surprisingly, and consistent with previous research (Goodwin, 1988; Hermann, 1992; van der

Kolk, 2005), the current study found significant relationships between experiencing potentially

traumatic events (PTEs) in childhood (e.g., childhood abuse) and also throughout one’s lifetime

and the development of trauma symptomology. Additionally, factors hypothesized to be

protective in relation to experiencing PTEs were explored: experiencing a more positive family

environment and having a more secure attachment style. Significant relationships were found

between family cohesion, expressiveness, conflict, and control, and trauma symptomology.

Finally, an individual’s attachment style was also found to be significantly related to reported

trauma symptoms. While identification of significant relationships in the current research cannot

discern directionality and certainly does not imply causation, the importance of these variables in

relation to trauma has been supported and warrants further investigation.

Trauma Symptomology

Of the current sample, 79% reported no to low incidence of childhood abuse/neglect

experiences. This observation aligns with current data, which indicate that 1 in 4 youth in the

U.S. experience some form of child abuse and maltreatment in their lifetimes (Finkelhor, Turner,

Ormond, & Hamby, 2013). Of those who reported childhood abuse, emotional abuse was the

most commonly experienced, with more than 10% of the sample reporting this PTE. When

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measuring across the lifetime, all 16 categories of PTEs were endorsed. Having been in a

transportation accident was the most common, with more than 62% reporting this PTE, and the

unexpected death of someone close (61%) was almost as common. Just over 12% of the sample

reported having experienced two or three PTEs in their lifetime, with the same percentage

endorsing that they had experienced nine or more. When both childhood and lifetime PTEs were

considered together, only 6.6% of participants reported having experienced none at all.

The first hypothesis in this study predicted that the number of potentially traumatic

events (PTEs) an individual experienced would be related to their trauma symptomology and

categorization in either a non-clinical, PTSD, or C-PTSD group. As hypothesized, higher

numbers of experienced PTEs were found to be related to higher incidence rates of both PTSD

and C-PTSD. Incidence of childhood PTEs were found to be 74% higher in those who reported

PTSD symptoms and 233% higher in those who reported C-PTSD symptoms. These results

aligned with current research in that the childhood PTE measure evaluated abuse experiences

and childhood abuse is known to result in trauma symptomology. Further, childhood abuse is

identified as one of the prolonged, chronic, and interpersonal experiences that are commonly

believed to contribute specifically to C-PTSD (Cloitre et al., 2013; Maercker et al., 2013; WHO,

2019).

The number of experienced PTEs in an individual’s lifetime was not found to be

significantly related to PTSD symptomology; however, it was found to be significant in relation

to C-PTSD. There was a 46% greater incidence of lifetime PTEs for those with C-PTSD

symptomology. Though the lifetime measure of PTEs used in this study did not contribute as

significantly as the childhood measure, the cross-sectional nature of this study and the wide age

range of undergraduates (18-66) in the sample may have contributed to mixed results. Further,

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classification based on PTE type-clusters has recently been found to strengthen correlational

results with trauma symptoms from this measure (Contractor, Weiss, Natesan Batley, & Elhai,

2020).

Family Environment

The second hypothesis predicted that a more positive family environment would be

related to less trauma symptoms. As hypothesized, when family environment was analyzed,

positive features were associated with less trauma symptomology. Results indicated that lower

scores on family cohesion, defined as the extent to which family members are concerned and

committed to the family and the degree to which family members are helpful and supportive of

each other, and expressiveness, the extent to which family members are allowed and encouraged

to act openly and express their feelings directly, were both associated with C-PTSD. Cohesive

and expressive families may have developed better communication styles, both within and

outside of familial relationships, that contribute to developing healthier coping skills and healing

following traumatic events. Families with these features may also offer more social closeness

and support that would further contribute to healing. Additionally, difficulties in emotional

regulation, self-identity, and interpersonal relatedness are indicative of having experienced

complex trauma and in fact, differentiate C-PTSD from PTSD. That less family support and

more complex trauma symptoms are significantly associated, is perhaps not surprising and

supports previous findings in this area of study.

Higher scores on family control, which measures rigidity of familial rules and

relationships, were associated with PTSD. Moreover, higher scores on family conflict were

associated with C-PTSD. This variable measured how commonly anger, aggression, and a

confrontational style is exhibited among family members. Controlling one’s emotions and using

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more confrontational communication styles may not be as adaptive as expressive communication

and further, may not contribute to cohesion. These results support numerous current studies that

offer a positive family environment as protective of mental health and well-being. In a study that

evaluated effects of family environment on psychosis, results indicated that a more negative

family environment increased risk and a more positive environment was protective in the

development of psychosis (Gonzalex-Pinto, de Azua, Ibanez, Otero-Cuesta, & Castro-Fornieles,

2011). A more negative family environment was associated with youth diagnoses of conduct

disorder and oppositional defiant disorder, as well as predicted worse health outcomes (e.g.,

psychiatric hospitalization, substance misuse; Rey, Walter, Plapp, & Denshire, 2000).

Additionally, family conflict in youth has been linked to insomnia in adulthood (Gregory,

Avshalom, Moffitt, & Poulton, 2006). Having specific knowledge of familial protective factors is

beneficial to building both theory and therapeutic treatment models, as well as strengthening the

foundation for individual resilience that is formed during childhood development.

No matter the shared event, parents and the familial environment play an essential role in

youth response and healthy adjustment to traumatic events. Eisenberg and Silver (2011)

reviewed the literature regarding children’s coping and emotional regulation, and their parents’

roles in shaping their responses, in relation to the September 11th, 2001 terrorist attacks (9/11).

Findings indicated that parents played significant roles in determining their children’s well-

being. When parents encouraged emotional expression, positive reframing, and acceptance of

emotional reactions, their children experienced lower levels of distress (Gil-Rivas, Silver,

Holman, McIntosh, & Poulin, 2007). Further, parental rejection, avoidance of information-

sharing about the trauma, or distancing from their children’s emotional responses has been

63
shown to increase children’s negative responses to traumatic events (Charuvastra & Cloitre,

2008).

Knowledge of individual and familial strengths and weaknesses is beneficial in

addressing these. Both individual and family therapy is of higher quality and more useful when

knowledge of these factors is incorporated into the work being addressed. Individuals may gain

confidence when they are knowledgeable regarding their abilities and competence. In the same

regard, when awareness increases in reference to particularly beneficial areas that need

improvement, individuals and families are able to build upon these.

Attachment

The third hypothesis predicted that an individual’s attachment style would be related to

trauma symptomology. When focusing on attachment and its relationship with trauma, it is worth

noting that more than 90% of the current study sample reported having an adult attachment

figure who loved and supported them, and with whom they felt close. The majority of

respondents identified their mother or step-mother as that person (37%). Participants also

identified their father or step-father (30%) or both parents (12%) as primary attachment figures.

While the current study did not determine these individuals’ attachment styles, consideration

should be given to secure attachment styles, as they are related to more positive functioning

within romantic and familial relationships (Paley et al., 1999). In a study evaluating attachment

in marital relationships, Paley et al. found that securely attached wives were effective problem-

solvers, and that they expressed more positive affect and less withdrawal than insecure wives. In

other research, securely attached men have been found to provide greater support to their

partners during a stressful situation than insecure men (Simpson, Rholes, & Nelligan, 1992).

Secure individuals are generally more able to regulate emotions effectively and thus, are more

64
likely to develop closeness and intimacy (Ben-Naim et al., 2013). They are also more likely to

report experiencing overall satisfaction in their relationships.

Each of three measurements of attachment were evaluated separately in relation to trauma

symptomology. First, it was predicted that PTSD symptomology would be related to higher

scores on the anxiety dimension of attachment. Contrary to this prediction, these scores were not

found to be significantly related to PTSD. As previously mentioned, this study was under-

powered, and specifically, the ITQ-identified PTSD group contained only 23 participants.

Results may have been different if a larger sample had been obtained. Attachment anxiety scores

did, however, indicate a significant relationship with C-PTSD symptomology. The chronic,

prolonged, or repeated nature of traumatic events related to C-PTSD may interrupt healthy

developmental pathways or positive schemas needed to support secure attachment.

Anxiously attached individuals have more difficulty maneuvering in close and romantic

relationships than those who are securely attached. In a study of the role of attachment in

emotion regulation during relationship conflict, Ben-Naim et al. (2013) found that these

individuals struggle to hold their negative thoughts and feelings in check. They appear to be less

able to discriminate when sharing their emotions with their partners. During stressful

interactions, their disclosure of negative emotions (e.g., contempt, sadness) increased and that of

positive emotions decreased. The authors indicated that this behavior was even more evident in

those individuals who were rated as high in anxious attachment. Anxious partners tend to regard

threatening situations in an exaggerated way and react prematurely to perceived danger (Ben-

Naim et al.).

Next, it was predicted that C-PTSD symptomology would be related to higher scores on

the avoidance dimension of attachment. As hypothesized, this relationship was found to be

65
significant. Disorganized or mixed styles of attachment have been more frequently linked to

complex trauma (Ford & Courtois, 2009; Jacobs, Boyce, Ilan-Clarke, & Bifulco, 2019). Current

research supported this finding, with both anxious and avoidant attachment styles associated with

C-PTSD. Individuals with avoidant attachment styles tend to exhibit an inflated sense of self-

sufficiency and independence, less often seeking support from others (Ein-Dor, Mikulincer, &

Shaver, 2011). They may use suppression or distancing from negative emotions and experiences

as emotional coping methods (Ben-Naim et al., 2013). While suppression can result in negative

physical and psychological consequences for some, it appears to be less harmful for avoidant

individuals. Avoidance, detachment, and suppression appear to meet these individuals’

attachment needs. These strategies may serve the function of shutting down both the attachment

system of the avoidant caregiver and the support seeking partner, forcing that individual to find

other ways to deal with their needs (Feeney & Collins, 2001).

Finally, it was predicted that the overall attachment classification would be related to

distinct categorization of trauma symptomology. Significantly, almost half of the study sample

(46%) reported secure attachment and also belonged to the non-clinical trauma symptom

category. As hypothesized, there were far fewer individuals with C-PTSD symptomology within

the group who identified as more securely attached. Further, more individuals who met criteria

for C-PTSD had less secure attachment, belonging to either the pre-occupied or fearfully

avoidant attachment categories. Contrary to predicted outcomes, there was no significant

relationship found between any of the elements of attachment and a PTSD categorization.

Human attachment is currently believed to be a biological, emotionally bonding,

reciprocally related behavioral system that increases our chance of survival early in life and

guides our feelings of security throughout adulthood (Hazan & Shaver, 1994). Insecure

66
attachment in adulthood is likely to contribute to relational issues that are most evident in close

relationships. According to Bowlby (1988), methods that may improve insecure attachment

include gaining an understanding of internal working models and having corrective emotional

experience within a close relationship. Attachment-based models of therapy, including Circle of

Security and Dyadic Developmental Psychotherapy, address youth attachment relationships

within the family system in order to build psychological health and resilience. Emotionally

focused therapy (EFT) for couples offers an attachment-based treatment approach providing

psychoeducation about attachment histories and an opportunity to facilitate restorative

experiences for couples. Each of these methods addresses bidirectional attachment and builds

emotional wellness.

Possible Protective Factors in Relation to Trauma Symptomology

The fourth and final hypothesis predicted that the factors of a more positive family

environment and a more secure attachment style would account for significant variability in the

relationship between experiencing trauma and the development of symptoms. While numerous

other factors not addressed in this study may account for trauma symptomology, the logistic

regression model explained 23% of the variance in trauma symptomology and correctly

classified more than 84% of cases. Cloitre et al. (2009) found that trauma experiences during

childhood developmental stages are stronger contributors to symptomology. Consistent with

previous research, and in support of previous results from the current study, childhood abuse and

trauma exposure resulted in a 73% higher probability of endorsing trauma symptoms. Further,

less secure attachment, as measured by higher scores on attachment anxiety, resulted in a 65%

higher probability of meeting criteria for trauma symptomology.

67
 While lifetime PTE exposure and attachment avoidance did not explain significant

variance related to trauma categorization in this model, the family environment variables of

cohesion and conflict had significant relationships with trauma symptomology. Additionally,

family expressiveness was significantly associated with decreased odds of trauma

symptomology. Even though the effect size was small for these family variables, results support

previously reported research that family unity and cohesion strongly contribute to resiliency.

Implications and Future Research

The trauma experiences of the Native American population in this sample supports

previous research and strongly suggests further attention and investigation into the health

disparities of these individuals. While making up a small percentage (3.9%) of the total sample

size, Native Americans represented almost half (47%) of those who experienced complex trauma

symptomology. The vast health inequities of this population deserve considerable attention.

Given specific cultural differences and experiences, it is important to evaluate specific treatment

developments with this population. Further investigation and understanding of contributing

factors related to historical trauma, racism, and oppression, as well as building upon specific

factors related to increasing resiliency in this high-risk group is of utmost importance and long

over-due.

In addition to adding to the current research around complex trauma, these results have

important clinical implications. Frequently, primary focus is given to how to treat maladaptive

symptomology once it is established. While it is necessary to develop and implement effective

treatment models, attention should also be focused on variables that may provide protection and

contribute to healthy developmental pathways. For instance, interventions directed at improving

family environment have been shown to reduce conduct problems in youth (Rey, Walter, Plapp,

68
& Denshire, 2000). The current study provided preliminary support for the potentially protective

elements of family environment (cohesion, expressiveness, conflict, and control) and attachment

(anxiety and avoidance) that were significantly related to reduced trauma symptomology and

could be specifically targeted in treatment.

Special consideration should be given in treatment to the significant role family plays in

building both risk and resiliency. While this variable is included by necessity when working with

youth who are still living within their family system, focus on family factors in work with adult

individuals should also be considered. Family considerations and inclusion in treatment

modalities is essential in the treatment of trauma. When addressing persistent and complex

trauma symptomology, understanding the negative contribution of weaknesses within the family

system and the importance of strengthening these relations may significantly increase positive

outcomes.

The current study also contributes to the vast literature suggesting that specific

consideration be given to complex trauma and C-PTSD. The pronounced differences in both the

experience of trauma and resulting symptomology between PTSD and C-PTSD clearly justify

further investigation. Hermann proposed more comprehensive evaluation in these areas more

than two decades ago. Despite increased research and findings, as well as the inclusion of C-

PTSD in the most recent ICD, C-PTSD is still not given sufficient consideration in the DSM. It

is time for this omission to be rectified.

More research is needed to understand significant relationships between trauma type,

number of experiences, and development of symptoms in order to refine trauma-informed and

trauma-focused therapeutic methods that focus on complex trauma. Cloitre (2015) suggests that

consideration must be given to the heterogeneity of the trauma population. Profiles of complex

69
trauma throughout the lifespan will contribute to the understanding of proposed core symptoms

and to the development of interventions that match individual client needs (Cloitre, 2015). In

order to identify the optimal identification and treatment for a traumatized individual, reliable

symptom profiles that align with distinct outcomes must be identified.

Limitations

The present study has a number of methodological limitations. As with any cross-

sectional survey, causation cannot be implied. In addition, the measures used were self-report

questionnaires. While this method has valid strengths specific to trauma research as previously

described, it most certainly has well-known weaknesses as well (e.g., being subject to the biases

and limitations of retrospective reports). It has been suggested that symptomatology would be

more accurately determined if multiple informants (Lanktree et al., 2008) and multi-method

assessments, including interviews and/or observations were used (Courtois, 2004; Hoyle, Harris,

& Judd, 2002). As such, future studies may expand on current research by conducting clinician-

conducted interviews or obtaining collateral reports to more confidently determine symptoms

and categorization.

This research was limited by the relatively homogenous nature of the participants,

particularly in regard to race/ethnicity and educational status. The majority of participants (84%)

were White/non-Hispanic. Future research would expand on the current study by investigating a

more diverse sample, to include populations who experience higher levels of trauma (e.g.,

sexually- and gender-diverse individuals). Further, conducting research with a college population

sample may be seen as a disadvantage when consideration is given to generalizability. However,

the International Trauma Questionnaire (ITQ) for the ICD-11 has not yet been evaluated in

70
relation to a non-clinical population or a college sample. These results will contribute to growing

literature regarding this measure.

Additionally, when childhood abuse or neglect is the traumatic experience resulting in

trauma symptomatology, it may be impossible to completely disentangle familial factors and

their contributions to risk and resiliency. An individual may have experienced caregivers, family

members, or a home environment that contributed both protective and injurious elements. While

these variables certainly overlap, each individual included in the current study reported on the

entirety of their traumatic experiences and on the same components of the specific factors

evaluated. An additional limitation is the relatively small n for some subgroups (e.g., 23

participants met criteria for PTSD, 59 met criteria for C-PTSD), offering less power than

anticipated.

Although, 84% of cases were correctly classified in the logistic regression, the effect

sizes were small. These results suggest that, as would be expected, numerous other factors not

accounted for in the present study may account for trauma symptomology. These limitations

notwithstanding, the present study has a number of strengths. These include well-validated

instruments that yielded good internal consistency in the present sample and results that support

previous research and theory.

Summary

In conclusion, the primary objective of the current study was to contribute knowledge to

the growing literature on complex trauma and possible protective factors that may contribute to

less trauma symptomology. Results indicate the high frequency of trauma exposure among

college undergraduates. That is, more than 93 percent of the respondents had experienced one or

more potentially traumatic events in their lifetime. Trauma is known to contribute to serious

71
psychological and physiological health concerns and the incredibly high incidence rate in a

college population underscores the seriousness of the problem. Identification of factors that

contribute to both risk and to resilience is critical in order to improve services and resources for

individuals, families, and their communities.

Results from the current study were consistent with previous research regarding the

relationship between potentially traumatic events (PTEs) and trauma symptomology and

categorization. Traumatic events that occur over extended periods of time during childhood and

hinder meeting developmental milestones (e.g., childhood abuse) are believed to significantly

contribute to complex trauma; this relationship was supported. The current study also found

evidence for associations between the number of PTEs experienced and trauma symptoms of

both PTSD and C-PTSD.

Further, the current research contributed preliminary information on relationships

between experiencing PTEs, developing trauma symptomology, and the potentially protective

factors of positive family environment and secure attachment. Of the seven elements evaluated in

this study, the family environment subscales (1) cohesion, (2) expressiveness, (3) conflict, and

(4) control, as well as the attachment variables (1) anxiety and (2) avoidance, were all found to

be associated with trauma symptomology. Only family organization had no supporting evidence

of a significant relationship.

The findings of this study support further exploration of factors that promote resilience in

relation to both PTSD and C-PTSD. By developing knowledge around those factors that build

resilience and contribute to mental health and wellness in the face of adversity and trauma, both

childhood and lifetime developmental pathways may be strengthened. Understanding risk and

72
protective variables is essential in being better equipped to promote healthy development in the

face of complex trauma.

73
 Appendix A

Informed Consent

Thank you for agreeing to participate in this survey. The purpose of this study is to learn about

ways in which our past experiences are related to how we currently think, feel, and relate to

others. Most of these questions will ask you to choose from a set selection of options.

Sometimes, this will feel really easy to do and one of the options will feel like it accurately fits

what you think or feel. Other times, you may be torn between one or two options, and that is

okay! Just choose the option that best describes your experiences. There are no right or wrong

answers to these questions.

Who should complete this survey?

Undergraduate college students who are 18 years or older are eligible to participate in this

survey.

How do I complete this survey?

The survey contains two types of questions: Questions that require you to check a box associated

with the response that best describes your experiences, and questions where you are asked to

type your answers in a text box presented beneath the question. Most questions will ask you to

simply check a box.

How long does it take to complete the survey?

Answering the survey should take approximately 45 minutes to one hour to complete.

Are there any risks associated with taking this survey?

We believe that the likely risks of completing this survey are minimal. However, some of the

questions are about experiences you may have had – or are currently having – in regard to being

hurt physically, sexually, or emotionally. Because of this, some of the questions may make you

74
uncomfortable or be distressing to you. If you become distressed or desire assistance during or

after taking the survey, you should contact either or both of the following numbers:

Counseling Services…………………………………….243-4711

Student Advocacy Resource Center…………………….243-6559

Suicide Prevention Lifeline……………………………...1-800-273-TALK (8255)

Please also note that you may exit out of the survey at any time. There will be an option at the

end of every page that allows you to discontinue the survey.

Are there any benefits for me in completing this survey?

There are no direct benefits anticipated for you from answering questions on this survey.

However, this survey will provide valuable information about how past experiences influence

current experiences. This information may help with the development of effective treatments for

those with negative past experiences.

You may also be compensated for your time by receiving research credit in your psychology

course. If you are interested in receiving research credit, please follow the link at the end of this

survey. This link will take you to a separate page where you can enter your contact information.

Your contact information will in no way be connected to your responses.

To request more information about this survey or the study, please email Susan Ocean, M.A. at

[email protected]. If you have any questions regarding your rights as a research

participant, contact the UM Institutional Review Board (IRB) at (406) 243-6672.

Please print or save a copy of this page for your records.

Clicking below and continuing this survey indicates that I am female, I am 18 years or older, I

have read the description of the study, and I agree to participate in this study.

-I agree -I disagree

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 Appendix B

Demographic Information

1. How old are you? (please answer in years, and in number format only. e.g.: 21 years, 7
months = “21”)

2. What is your current class standing?

a. Freshman
b. Sophomore
c. Junior
d. Senior
e. Graduate (Master Degree)
f. Graduate (Ph.D.)
g. Graduate (Ed.D.)
h. UM Law Student
i. Unsure

3. What is your racial/ethnic background?

a. White/non-Hispanic
b. Black
c. Hispanic
d. Asian or Pacific Islander
e. American Indian/Alaska Native
f. Two or more races
g. Other _________

4. What is your current relationship status?

a. Single, not dating
b. In a relationship, not engaged or married
c. In a relationship, engaged
d. Married
e. Divorced or separated
f. Widowed

5. How long have you been in this relationship? (Please answer in months, and in number
format only. E.g.: 5 years = “60”)

6. When you were growing up, did you have an adult who loved and supported you and that
you felt close with?

7. Who was this person?

8. In general, would you say your health is…

a. Excellent
b. Very Good

76
c. Good
d. Fair
e. Poor

77
 Appendix C

Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1997)

Instructions: These questions ask about some of your experiences growing up as a child and as

a teenager. Although these questions are of a personal nature, please try to answer as honestly as

you can. For each question, select the response that best describes how you feel.

When I was growing up…

1 = Never True 2 = Rarely True 3 = Sometimes True

4 = Often True 5 = Very Often True

1. I didn’t have enough to eat.

2. I knew that there was someone to take care of me and protect me.

3. People in my family called me things like “stupid,” “lazy,” or “ugly.”

4. My parents were too drunk or high to take care of the family.

5. There was someone in my family who helped me feel that I was important or special.

6. I had to wear dirty clothes.

7. I felt loved.

8. I thought that my parents wished I had never been born.

9. I got hit so hard by someone in my family that I had to see a doctor or go to the hospital.

10. There was nothing I wanted to change about my family.

11. People in my family hit me so hard that it left me with bruises or marks.

12. I was punished with a belt, a board, a cord, or some other hard object.

13. People in my family looked out for each other.

14. People in my family said hurtful or insulting things to me.

15. I believe that I was physically abused.

76
16. I had the perfect childhood.

17. I got hit or beaten so badly that it was noticed by someone like a teacher, neighbor, or

doctor.

18. I felt that someone in my family hated me.

19. People in my family felt close to each other.

20. Someone tried to touch me in a sexual way, or tried to make me touch them.

21. Someone threatened to hurt me or tell lies about me unless I did something sexual with

them.

22. I had the best family in the world.

23. Someone tried to make me do sexual things or watch sexual things.

24. Someone molested me.

25. I believe that I was emotionally abused.

26. There was someone to take me to the doctor if I needed it.

27. I believe that I was sexually abused.

28. My family was a source of strength and support.

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 Appendix D

Life Event Checklist, 5th Edition (LEC-5; Weathers et al., 2013)

Instructions: Below are a number of difficult or stressful things that sometimes happen to

people. For each event check one or more of the boxes to the right to indicate that (a) it happened

to you personally, (b) you witnessed it happen to someone else, (c) you learned about it, (d) you

don’t know if it applies to you, or (e) does not apply to you.

1. Natural disaster (for example, flood, hurricane, tornado, earthquake)

2. Fire or explosion

3. Transportation accident (for example, car accident, boat accident, train wreck, plane

crash)

4. Serious accident at work, home, or during recreational activity

5. Exposure to toxic substance (for example, dangerous chemicals, radiation)

6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)

7. Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun,

bomb)

8. Sexual assault (rape, attempted rape, made to perform any type of sexual act through

force of threat of harm)

9. Other unwanted or uncomfortable sexual experience

10. Combat or exposure to a war-zone (in the military or as a civilian)

11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)

12. Life-threatening illness or injury

13. Severe human suffering

14. Sudden, violent death (for example, homicide, suicide)

15. Sudden, unexpected death of someone close to you

78
16. Serious injury, harm, or death you caused to someone else

17. Any other very stressful event or experience

18. What was that event or experience? _________________________

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 Appendix E

Experiences in Close Relationships – Revised Questionnaire (ECR-R; Fraley et al., 2000)

Instructions: The statements below concern how you feel in emotionally intimate relationships.

We are interested in how you generally experience relationships, not just in what is happening in

a current relationship. Respond to each statement by clicking a circle to indicate how much you

agree or disagree with the statement.

1 = strongly disagree 2 = disagree 3 = somewhat disagree 4 = neither agree nor disagree 5 =

somewhat agree 6 = agree 7 = strongly agree

1. I'm afraid that I will lose my partner's love.

2. I often worry that my partner will not want to stay with me.

3. I often worry that my partner doesn't really love me.

4. I worry that romantic partners won’t care about me as much as I care about them.

5. I often wish that my partner's feelings for me were as strong as my feelings for him or her.

6. I worry a lot about my relationships.

7. When my partner is out of sight, I worry that he or she might become interested in someone

else.

8. When I show my feelings for romantic partners, I'm afraid they will not feel the same about

me.

9. I rarely worry about my partner leaving me.

10. My romantic partner makes me doubt myself.

11. I do not often worry about being abandoned.

12. I find that my partner(s) don't want to get as close as I would like.

13. Sometimes romantic partners change their feelings about me for no apparent reason.

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14. My desire to be very close sometimes scares people away.

15. I'm afraid that once a romantic partner gets to know me, he or she won't like who I really am.

16. It makes me mad that I don't get the affection and support I need from my partner.

17. I worry that I won't measure up to other people.

18. My partner only seems to notice me when I’m angry.

19. I prefer not to show a partner how I feel deep down.

20. I feel comfortable sharing my private thoughts and feelings with my partner.

21. I find it difficult to allow myself to depend on romantic partners.

22. I am very comfortable being close to romantic partners.

23. I don't feel comfortable opening up to romantic partners.

24. I prefer not to be too close to romantic partners.

25. I get uncomfortable when a romantic partner wants to be very close.

26. I find it relatively easy to get close to my partner.

27. It's not difficult for me to get close to my partner.

28. I usually discuss my problems and concerns with my partner.

29. It helps to turn to my romantic partner in times of need.

30. I tell my partner just about everything.

31. I talk things over with my partner.

32. I am nervous when partners get too close to me.

33. I feel comfortable depending on romantic partners.

34. I find it easy to depend on romantic partners.

35. It's easy for me to be affectionate with my partner.

36. My partner really understands me and my needs.

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 Appendix F

Family Environment Scale (FES; Moos & Moos, 1981)

There are 90 statements in this booklet. They are statements about families. You are to decide

which of these statements are true of your family of origin and which are false. If you think the

statement is “true” or mostly “true” of the family you were raised in, make a “T” next to the

statement. If you think the statement is “false” or mostly “false” of your family, make an “F”

next to the statement.

You may feel that some of the statements are true for some family members and false for others.

Mark “T” if the statement is true for most members. Mark “F” if the statement is false for most

members. If the members are evenly divided, decide which the overall stronger impression is and

answer accordingly.

Remember, we would like to know what your family seems like to you. So do not try to figure

out how other members see your family, but do give us your general impression of your family

for each statement.

1. Family members really help and support one another.

2. Family members often keep their feelings to themselves.

3. We fight a lot in our family.

4. We don’t do things on our own very often in our family.

5. We feel it is important to be the best at whatever you do.

6. We often talk about political and social problems.

7. We spend most weekends and evenings at home.

8. Family members attend church, synagogue, Sunday school (or similar) fairly often.

9. Activities in our family are pretty carefully planned.

82
10. Family members are rarely ordered around.

11. We often seem to be killing time at home.

12. We say anything we want to around home.

13. Family members rarely become openly angry.

14. In our family, we are strongly encouraged to be independent.

15. Getting ahead in life is very important in our family.

16. We rarely go to lectures, plays, or concerts.

17. Friends often come over for dinner or to visit.

18. We don’t say prayers in our family.

19. We are generally very neat and orderly.

20. There are very few rules to follow in our family.

21. We put a lot of energy into what we do at home.

22. It’s hard to “blow off steam” at home without upsetting somebody.

23. Family members sometimes get so angry they throw things.

24. We think things out for ourselves in our family.

25. How much money a person makes is not very important to us.

26. Learning about new and different things is very important in our family.

27. Nobody in our family is active in sports, little league, bowling, etc.

28. We often talk about the religious meaning of Christmas, Passover, or other holidays.

29. It’s often hard to find things when you need them in our household.

30. There is one family member who makes most of the decisions.

31. There is a feeling of togetherness in our family.

32. We tell each other about our personal problems.

83
33. Family members hardly ever lose their tempers.

34. We come and go as want in our family.

35. We believe in competition and “may the best person win.”

36. We are not that interested in cultural activities.

37. We often go to the movies, sports events, camping, etc.

38. We don’t believe in heaven or hell.

39. Being on time is very important in our family.

40. There are set ways of doing things at home.

41. We rarely volunteer when something has to be done at home.

42. If we feel like doing something on the spur of the moment, we often just pick up and go.

43. Family members often criticize each other.

44. There is very little privacy in our family.

45. We always strive to do things just a little better the next time.

46. We rarely have intellectual discussions.

47. Everyone in our family has a hobby or two.

48. Family members have strict ideas about what is right and wrong.

49. People change their minds often in our family.

50. There is a strong emphasis on following rules in our family.

51. Family members rarely back each other up.

52. Someone usually gets upset if you complain in our family.

53. Family members sometimes hit each other.

54. Family members almost always rely on themselves when a problem comes up.

55. Family members rarely worry about job promotions, school grades, etc.

84
56. Someone in our family plays a musical instrument.

57. Family members are not very involved in recreational activities outside work or school.

58. We believe there are some things you just have to take on faith.

59. Family members make sure their rooms are neat.

60. Everyone has an equal say in family decisions.

61. There is very little group spirit in our family.

62. Money and paying bills is openly talked about in our family.

63. If there’s a disagreement in our family, we try hard to smooth things over and keep the

peace.

64. Family members strongly encourage each other to stand up for their rights.

65. In our family, we don’t try that hard to succeed.

66. Family members often go to the library.

67. Family members sometimes attend courses or take lessons for some hobby or interest

(outside of school).

68. In our family each person has different ideas about what is right and wrong.

69. Each person’s duties are clearly defined in our family.

70. We can do whatever we want to in our family.

71. We really get along well with each other.

72. We are usually careful about what we say to each other.

73. Family members often try to one-up or out-do each other.

74. It’s hard to be by yourself without hurting someone’s feelings in our household.

75. “Work before play” is the rule in our family.

76. Watching TV is more important than reading in our family.

85
77. Family members go out a lot.

78. The Bible, the Quran, or another religious doctrine, is a very important book/concept in

our home.

79. Money is not handled very carefully in our family.

80. Rules are pretty inflexible in our household.

81. There is plenty of time and attention for everyone in our family.

82. There are a lot of spontaneous discussions in our family.

83. In our family, we believe you don’t ever get anywhere by raising your voice.

84. We are not really encouraged to speak up for ourselves in our family.

85. Family members are often compared with others as to how well they are doing at work or

school.

86. Family members really like music, art, and literature.

87. Our main form of entertainment is watching TV or listening to the radio.

88. Family members believe that if you sin you will be punished.

89. Dishes are usually done immediately after eating.

90. You can’t get away with much in our family.

86
 Appendix G

The International Trauma Questionnaire (ITQ; Cloitre, Roberts, Bisson, & Brewin, 2018)

International Trauma Questionnaire

Instructions: Please identify the experience that troubles you most and answer the questions in relation
to this experience.

Brief description of the experience _______________________________________________

When did the experience occur? (circle one)

a. less than 6 months ago
b. 6 to 12 months ago
c. 1 to 5 years ago
d. 5 to 10 years ago
e. 10 to 20 years ago
f. more than 20 years ago

Below are a number of problems that people sometimes report in response to traumatic or stressful life
events. Please read each item carefully, then circle one of the numbers to the right to indicate how much
you have been bothered by that problem in the past month.
Not A little Moderately Quite Extremely
at all bit a bit
1. Having upsetting dreams that replay part of the
experience or are clearly related to the experience? 0 1 2 3 4

2. Having powerful images or memories that sometimes

come into your mind in which you feel the experience 0 1 2 3 4
is happening again in the here and now?

3. Avoiding internal reminders of the experience (for

example, thoughts, feelings, or physical sensations)? 0 1 2 3 4

4. Avoiding external reminders of the experience (for

example, people, places, conversations, objects, 0 1 2 3 4
activities, or situations)?

5. Being “super-alert”, watchful, or on guard? 0 1 2 3 4

6. Feeling jumpy or easily startled? 0 1 2 3 4

In the past month have the above problems:

7. Affected your relationships or social life? 0 1 2 3 4

8. Affected your work or ability to work? 0 1 2 3 4

87
9. Affected any other important part of your life such
as parenting, or school or college work, or other 0 1 2 3 4
important activities?

Below are problems that people who have had stressful or traumatic events sometimes experience. The
questions refer to ways you typically feel, ways you typically think about yourself and ways you typically
relate to others. Answer the following thinking about how true each statement is of you.

Not A Moderately Quit Extremely

How true is this of you? at little a bit
all bit
1. When I am upset, it takes me a long time to calm
down. 0 1 2 3 4

2. I feel numb or emotionally shut down. 0 1 2 3 4

3. I feel like a failure. 0 1 2 3 4

4. I feel worthless. 0 1 2 3 4

5. I feel distant or cut off from people. 0 1 2 3 4

6. I find it hard to stay emotionally close to people. 0 1 2 3 4

In the past month, have the above problems in emotions, in beliefs about yourself and in
relationships:

7. Created concern or distress about your relationships

0 1 2 3 4
or social life?

8. Affected your work or ability to work? 0 1 2 3 4

9. Affected any other important parts of your life such

0 1 2 3 4
as parenting, or school or college work, or other
important activities?

88
 References

Ainsworth, M.D.S., Blehar, M.C., Waters, E., & Wall, S. (1978). Theoretical background. In

Patterns of Attachment: A Psychological Study of the Strange Situation (pp. 3-28).

Hillsdale, NJ: Lawrence Erlbaum and Associates.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders

(Revised 4th ed.). Washington, DC: Author.

American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental

Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

Barry, R. A., & Lawrence, E. (2013). “Don’t stand so close to me”: An attachment perspective of

disengagement and avoidance in marriage. Journal of Family Psychology, 27(3),

484-494.

Ben-Naim, S., Hirschberger, G., Ein-Dor, T., & Mikulincer, M. (2013). An experimental study

of emotion regulation during relationships conflict interactions: The moderating role

of attachment orientations. Emotion, 13(3), 506-519.

Bernstein, D. P. & Fink, L. (1997). The Childhood Trauma Questionnaire [Measurement

instrument] Retrieved from https://www.statisticssolutions.com/childhood-trauma-

questionnaire-ctq/.

Birnbaum, G. E., Reis, H. T., Mikulincer, M., Gillath, O., & Orpaz, A. (2006). When sex is more

than just sex: Attachment orientations, sexual experience, and relationship quality.

Journal of Personality and Social Psychology, 91(5), 929-943.

Bonanno, G. (2008). Loss, trauma, and human resilience: Have we underestimated the human

capacity to thrive after extremely aversive events? Psychological Trauma: Theory,

Research, Practice, and Policy 5(1), 101-113.

89
Bowlby, J. (1951). Maternal care and mental health. Geneva: World Health Organization.

Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.

Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation: Anxiety and anger. New York:

Basic Books.

Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. London:

Routledge.

Brennan, N., Clark, C., & Shaver, P. (1998). Self-report measurement of adult attachment: An

integrative overview. In J. Simpson & W. Rholes (Eds.), Attachment theory and close

relationships (pp. 46-76): New York: Guilford Press.

Breslau, N., Davis, G. C., Peterson, E. L., & Schultz, L. R. (2000). A second look at comorbidity

in victims of trauma: The posttraumatic stress disorder-major depression connection.

Biological Psychiatry, 48, 902-909.

Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth.

Developmental Psychology, 28, 759-775.

Briere, J. & Jordan, C. E. (2009). Childhood maltreatment, intervening variables, and adult

psychological difficulties in women: An overview. Trauma, Violenace, & Abuse, 10,

375-388.

Briere, J., Hodges, M., & Godbout, N. (2010). Traumatic stress, affect dysregulation, and

dysfunctional avoidance: A structural equation model. Journal of Traumatic Stress, 23,

767-774.

Briere, J., Kaltman, S., & Green, B. L. (2008). Accumulated childhoot trauma and symptom

complexity. Journal of Traumatic Stress, 21, 223-226.

90
Brown, N. R., Kallivayalil, D., Mendelsohn, M., & Harvey, M. R. (2012). Working the double

edge: Unbraiding pathology and resiliency in the narratives of early-recovery trauma

survivors. Psychological Trauma: Theory, Research, Practice, and Policy 1, 102-111.

Bryant, R. A. (2012). Simplifying complex PTSD: Comment on Resick et al. (2012). Journal of

Traumatic Stress, 25, 252-253.

Campbell, R., Greeson, M. R., & Fehler-Cabral, G. (2014). Developing Recruitment Methods for

Vulnerable, Traumatized Adolescents: A Feminist Evaluation Approach. American Journal

of Evaluation, 35(1), 73-86. DOI: 10.1177/1098214013506251

Cloitre, M. (2015). The “one size fits all” approach to trauma treatment: Should we be satisfied?

European Journal of Psychotraumatology, 6, 1-8.

Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., and Green, B. L.

(2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best

practices. Journal of Traumatic Stress, 24, 615–27. https://doi.org/10.1002/jts.20697.

Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., and Maercker, A. (2013). Evidence for

proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of

Psychotraumatology, 4, 1–12. https://doi.org/10.3402/ejpt.v4i0.20706.

Cloitre, M., Roberts, N. P., Bisson, J. I., & Brewin, C. R. (2017). The International Trauma

Questionnaire (ITQ) (Unpublished Measure).

Cloitre, M., Stolbach, B. C., Herman, J. L., van der Kolk, B., Pynoos, R., Wang, J., & Petkova,

E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative

trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22, 399-408.

91
Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L., Gan,

W., & Petkova, E. (2010). Treatment for PTSD related to childhood abuse: A randomized

controlled trial. American Journal of Psychiatry, 167, 915-924.

Cloitre, M., Stovall-McClough, C., Ferssizidis, P., & Charuvastra, A. (2008). Attachment

organization, emotion regulation, and expectations of support in a clinical sample of

women with childhood abuse histories. Journal of traumatic stress, 21, 282-289.

Contractor, A. A., Weiss, N. H., Natesan Batley, P., & Elhai, J. D. (2020). Clusters of trauma

types as measured by the Life Events Checklist for DSM-5. International Journal of

Stress Management, advanced online publication. http://dx.doi.org/10.1037/str0000179

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., & van der Kolk, B.

(2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 105-118.

Copeland, W. E., Gordon, K., Angold, A., & Costello, E. J. (2007). Traumatic events and

posttraumatic stress in childhood. Archives of General Psychiatry, 64, 577-584.

Costello, E. J., Erkanli, A., Fairbank, J. A., & Angold, A. (2002). The prevalence of potentially

traumatic events in childhood and adolescence. Journal of Traumatic Stress, 15(2), 99-

112

Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment.

Psychological Trauma: Theory, Research, Practice, and Policy, S, 86-100.

D’Andrea, W., Ford, J., Stolbach, B., Spinazzola, J., & van der Kolk, B. A. (2012).

Understanding interpersonal trauma in children: Why we need a developmentally

appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82, 187-200.

92
Deblinger, E., Steer, R. A., & Lippman, J. (1999). Sexually abused children suffering

posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment,

1, 310-321.

Ein-Dor, T., Mikulincer, M., & Shaver, P. R. (2011). Attachment insecurities and the processing

of threat-related information: Studying the schemas involved in insecure people’s

coping strategies. Journal of Personality and Social Psychology, 101, 78-93.

Elklit, A., Hyland, P., and Shevlin, M. (2014). Evidence of symptom profiles consistent with

posttraumatic stress disorder and complex posttraumatic stress disorder in different trauma

samples. European Journal of Psychotraumatology, 5, 1–10.

https://doi.org/10.3402/ejpt.v5.24221.

Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3: A flexible statistical

power analysis program for the social, behavioral, and biomedical sciences. Behavior

Research Methods, 39, 175-191.

Feeney, B. C., & Collins, N. L. (2001). Predictors of caregiving in adult intimate relationships:

An attachment theoretical perspective. Journal of Personality and Social Psychology,

80(6), 972-994.

Feeny, N. C., Foa, E. B., Treadwell, K. R. H., & March, J. (2004). Posttraumatic stress disorder

in youth: A critical review of the cognitive and behavioral treatment outcome literature.

Professional Psychology: Research and Practice, 35(5), 466-476.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., …

Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many

of the leading causes of death in adults: The adverse childhood experiences (ACE) study.

American Journal of Preventative Medicine, 14, 245-258.

93
Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected

component in child victimization. Child Abuse & Neglect, 31, 7-26.

Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. (2005). The victimization of children and

youth: A comprehensive, national survey. Child Maltreatment, 10(1), 5-25.

Finkelhor, D., Turner, H. A., Ormond, R., & Hamby, S. L. (2013). Violence, crime, and abuse

exposure in a national sample of children and youth: An update. Journal of American

Medical Association Pediatrics, 167(7), 614-621.

Follette, V. M., Polusny, M. A., Bechtle, A. E., & Naugle, A. E. (1996). Cumulative trauma: The

impact of child sexual abuse, adult sexual assault, and spouse abuse. Journal of Traumatic

Stress, 9, 25-35.

Ford, J. D. (2017). Complex trauma and complex posttraumatic stress disorder. In APA

Handbook of Trauma Psychology: Foundations in Knowledge (Vol. 1), edited by Steven N.

Gold, Vol. 1:281–305, Chapter xxii, 624 Pages. American Psychological Association; DC,

2017.

https://search.proquest.com/psycinfo/docview/1933894051/abstract/6422F7D62C7448EEP

Q/3.

Ford, J. D. & Courtois, C. A. (2009). Defining and understanding complex trauma and complex

traumatic stress disorders in C. Courtois & J. Ford (Eds.), Treating complex traumatic stress

disorders: An evidence-based guide (pp. 13-30). New York: Guilford Press.

Fraley, R. C. & Shaver, P. R. (2000). Adult romantic attachment: Theoretical developments,

emerging controversies, and unanswered questions. Review of General Psychology, 4,

132-154. doi:10.1037/1089-2680.4.2.132

94
Fraley, R. C. & Waller, N. G. (1998). Adult attachment patterns: A test of the typological model

in J. Simpson & W. Rholes (Eds.), Attachment theory and close relationships (pp. 77-

114). New York: Guilford Press.

Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item-response theory analysis of self-

report measures of adult attachment. Journal of Personality and Social Psychology, 78, 350-

365.

Friedman, M. J., Resick, P. A., Bryant, R. A., and Brewin, C. R. (2011). Considering PTSD for

DSM-5. Depression and Anxiety, 28, 750–69. https://doi.org/10.1002/da.20767.

Gelinas, D. (1983). The persisting negative effects of incest. Psychiatry, 46, 312-332.

Ghasemi, A. & Zahediasl, S. (2012). Normality tests for statistical analysis: A guide for non-

statisticians. International Journal for Endocrinology and Metabolism, 10(2), 486-489.

https:// DOI:10.5812/ijem.3505.

González-Pinto, A., de Azúa, S, Ibáñez, B., Otero-Cuesta, S., Castro-Fornieles, J., et al. (2011).

Can positive family factors be protective against the development of psychosis?

Psychiatry Research, 186(1), 28-33.

Goodwin, J. (1988). Posttraumatic symptoms in abused children. Journal of Traumatic Stress, 1,

475-488.

Gregory, A. M., Avshalom, C., Moffitt, T. E., and Poulton, R. (2006). Family conflict in

childhood: A predictor of later insomnia. Sleep, 29(8), 1063-1067.

Hazan, C. & Shaver, P. R. (1994). Attachment as an organizational framework for research on

close relationships. Psychological Inquiry, 5(1), 1-22.

Herman, J.L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated

trauma. Journal of Traumatic Stress, 5, 377-391.

95
Hidalgo, R. B., & Davidson, J. R. T. (2000). Posttraumatic stress disorder: Epidemiology and

health-related considerations. Journal of Clinical Psychiatry, 61, 5-13.

Hodges, M., Godbout, N., Briere, J., Lanktree, C., Gilbert, A., & Kletzka, N. T. (2013).

Cumulative trauma and symptom complexity in children: A path analysis. Child Abuse &

Neglect, 37, 891–898. doi:10.1016/j.chiabu.2013.04.001.

Hyland, P., Shevlin, M., Brewin, C. R., Cloitre, M., Downes, A. J., Jumbe, S., Karatzias, T.,

Bisson, J. I., and Roberts, N. P. (2017). Validation of posttraumatic stress disorder (PTSD)

and complex PTSD using the international trauma questionnaire. Acta Psychiatrica

Scandinavica, 136, 313–22. https://doi.org/10.1111/acps.12771.

Jacobs, C., Boyce, N., Ilan-Clarke, Y., & Bifulco, A. (2019). Assessing attachment style in

traumatized adolescents in residential care: A case approach. Child Abuse and

Maltreatment: Interdisciplinary Journal, 21(1), 39-54.

Jonkman, C. S., Verlinden, E., Bolle, E. A., Boer, F., and Lindauer, R. J. L. (2013). Traumatic

stress symptomatology after child maltreatment and single traumatic events: Different

profiles. Journal of Traumatic Stress, 26, 225–32. https://doi.org/10.1002/jts.21792.

Karam, E. G., Friedman, M. J., Hill, E. D., Kessler, R. C., McLaughlin, K. A., Petukhova, M. …

Koenen, K. C. (2014). Cumulative traumas and risk thresholds: 12-month PTSD in the

World Mental Health (WMH) Surveys. Depression and Anxiety, 31, 130–42.

Kinniburgh, K. J., Blaustein, M., Spinazzola, J., van der Kolk, B. A. (2005). Attachment, self-

regulation, and competency: A comprehensive intervention framework for children with

complex trauma. Psychiatric Annals, 35, 424-430.

96
Kira, I. A., Lewandowski, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2008).

Measuring cumulative trauma dose, types, and profiles using a development-based

taxonomy of traumas. Traumatology, 14, 62-87.

Knefel, M., Garvert, D. W., Cloitre, M., & Lueger-Schuster, B. (2015). Update to an evaluation

of ICD-11 PTSD and complex PTSD criteria in a sample of adult survivors of childhood

institutional abuse by Knefel & Lueger-Schuster (2013): A latent profile analysis.

European Journal of Psychotraumatology, 6, 1-6.

Krystal, H. (Ed.). (1968). Massive psychic trauma. International Universities Press.

Laor, N., Wolmer, L., Mayes, L. C., Gershon, A., Weizman, R., & Cohen, D. J. (1997). Israeli

preschool children under scuds: A 30-month follow-up. Journal of the American

Academy of Child and Adolescent Psychiatry 36(3), 349-356.

Liem, J. H., James, J. B., O’Toole, J. G., & Boudewyn, A. C. (1997). Assessing resilience in

adults with histories of childhood sexual abuse. American Journal of Orthopsychiatry,

67(4), 594-606.

Lindauer, R. J. L. (2012). Child maltreatment – clinical PTSD diagnosis not enough?!: Comment

on Resick et al. (2012). Journal of Traumatic Stress, 25, 258-259.

Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical

evaluation and guidelines for future work. Child Development 71(3), 543-562.

Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., van Ommeren, M., Jones, L. M.,

Humayan, A., et al. (2013). Diagnosis and classification of disorders specifically associated

with stress: Proposals for ICD-11. World Psychiatry, 12, 198–206.

https://doi.org/10.1002/wps.20057.

97
Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment injuries in couples using

emotionally focused therapy: Steps toward forgiveness and reconciliation. Journal of

Consulting and Clinical Psychology, 74(6), 1055-1064.

Marinova, Z. & Maercker, A. (2015). Biological correlates of complex posttraumatic stress

disorder – state of research and future directions. European Journal of

Psychotraumatology, 6, 1-10.

Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American

Psychologist 56(3), 227-238.

Masten, A. S., Hubbard, J. J., Gest, S. D., Tellegen, A., Garmezy, N., & Ramirez, M. (1999).

Competence in the context of adversity: Pathways to resilience and maladaptation from

childhood to late adolescence. Development and Psychopathology, 11, 145-169.

McCormack, L. & Thomson, S. (2017). Complex trauma in childhood, a psychiatric diagnosis in

adulthood: Making meaning of a double-edged phenomenon. Psychological Trauma:

Theory, Research, Practice, and Policy, 9, 156-165.

McDonald, J. H. (2014). Handbook of Biological Statistics (3rd ed.). Sparky House Publishing,

Baltimore, Maryland.

McDonald, M. K. (2015). A measure development study for youth trauma exposure and

developmental trauma disorder (Doctoral dissertation). Retrieved from Scholarworks.

Graduate Student Theses, Dissertations, & Professional Papers. 4605.

Mikulincer, M. & Florian, V. (1998). The relationship between adult attachment styles and

emotional and cognitive reactions to stressful events. In J. Simpson & W. Rholes

(Eds.), Attachment theory and close relationships (pp. 143-165). New York:

Guildford Press.

98
Moos, R. (1981). Family Environment Scale. Palo Alto, California: Consulting Psychologists

Press.

Moos, R. H., & Moos, B. S. (1994). Family environment scale manual. Consulting Psychologists

Press.

Morgan, G.A., Leech, N. L., Gloeckner, G. W., & Barrett, K. C. (2011). IBM SPSS for

Introductory Statistics: Use and Interpretation (4th ed.). New York: Routledge Academic.

Paley, B., Cox, M. J., Burchinal, M. R., & Payne, C. C. (1999). Attachment and marital

functioning: Comparison of spouses with continuous-secure, earned-secure,

dismissing, and preoccupied attachment stances. Journal of Family Psychology,

13(4), 580-597.

Pederson, D. R., & Moran, G. (1999). The relationship imperative: Arguments for a broad

definition of attachment. Journal of Family Psychology, 13(4), 496-500.

Perkonigg, A., Höfler, M., Cloitre, M., Wittchen, H. U., Trautmann, S., & Maercker, A. (2015).

Evidence for two different ICD-11 posttraumatic stress disorders in a community sample

of adolescents and young adults. European Archives of Psychiatry and Clinical

Neurosicence, 266, 317-328.

Punamäki, R. L., Qouta, S., Miller, T., & El-Sarraj, E. (2011). Who are the resilient children in

conditions of military violence? Family- and child-related factors in a Palestinian

community sample. Peace and Conflict 17, 389-416.

Qouta, S., El-Sarraj, E., & Punamäki, R.L. (2001). Mental flexibility as resiliency factor among

children exposed to political violence. International Journal of Psychology, 36(1), 1-7.

R Core Team (2017). R: A language and environment for statistical computing. R Foundation for

Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.

99
Rees, S., Silove, D., Chey, T., Ivancic, L., Steel, Z., Creamer, M., Teesson, M., Bryant, R.,

McFarlane, A. C., Mills, K. L., Slade, T., Carragher, N., O’Donnell, M., & Forbes, D.

(2011). Lifetime prevalence of gender-based violence in women and the relationship with

mental disorders and psychological function. Journal of the American Medical

Association, 306, 513-521.

Resnick, M. D., Bearman, P. S., Blum, R. W., Bauman, K. E., Harris, K. M., Jones, J., . . . Udry,

J. R. (1997). Protecting adolescents from harm. Findings from the National Longitudinal

Study on Adolescent Health [Abstract]. The Journal of the American Medical

Asssociation 10, 823-832.

Rey, J., Walter, G., Plapp, J., & Denshire, E. (2000). Family environment in attention deficit

hyperactivity, oppositional defiant and conduct disorders. Australian and New

Zealand Journal of Psychiatry, 34(3), 453-457.

Roisman, G. I., Fortuna, K., & Holland, A. (2006). An experimental manipulation of

retrospectively defined earned and continuous attachment security. Child

Development, 77, 59-71.

Roisman, G. I., Fraley, R. C., & Belsky, J. (2007). A taxometric study of the Adult Attachment

Interview. Developmental Psychology, 43(3), 675-686.

Roisman, G.I., Madsen, S. D., Henninghausen, K. H., Sroufe, L. A., & Collins, W. A. (2001).

The coherence of dyadic behavior across parent-child and romantic relationships as

mediated by the internalized representation of experience. Attachment & Human

Development, 3, 156-172.

Rutter, M. (1999). Resilience concepts and findings: Implications for family therapy. Journal of

Family Therapy, 21, 119-144.

100
Scarr, S., & McCartney, K. (1983). How people make their own enviroments: A theory of

genotype-environgment effects. Child Development, 54, 424-435.

Schachner, D., Shaver, P., & Mikulincer, M. (2005). Patterns of nonverbal behavior and

sensitivity in the context of attachment relationships. Journal of Nonverbal Behavior, 29,

141-169.

Scheeringa, M. S., & Zeenah, C. H. (2001). A relational perspective on PTSD in early childhood.

Journal of Traumatic Stress 14(4), 799-815.

Simpson, J. A., Rholes, W. S., & Nelligan, J. S. (1992). Support seeking and support giving

within couples in an anxiety-provoking situation: The role of attachment styles.

Journal of Personality and Social Psychology, 62(3) 434-446.

Sroufe, L. A. (1997). Psychopathology as an outcome of development. Development and

Psychopathology 9, 251-268.

Stolbach, B. C., Garvert, D., Cloitre, M. (2014). A latent class analysis of PTSD and complex

trauma symptoms in urban trauma-exposed children and adolescents in Symposium

(Chair: Bradley C. Stolbach), Relationships between cumulative and complex trauma

exposure and symptoms in children: Implications for DSM and ICD diagnostic

classification; Miami, FL Nov, The 30th annual conference of The International Society

for Traumatic Stress Studies (ISTSS).

Tabachnick, B. G., & Fidell, L. S. (2001). Computer assisted research design and analysis.

Boston: Allyn and Bacon.

Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A

quantitative review of 25 years of research. Psychological Bulletin, 132, 959–92.

http://dx.doi.org.weblib.lib.umt.edu:8080/10.1037/0033-2909.132.6.959.

101
van der Kolk, B. A. (2005). Developmental Trauma Disorder. Psychiatric Annals, 35(5),401-

408.

Weathers, F. W., Blake, D. D., Schurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M.

(2013). The Life Events Checklist for DSM-5 (LEC-5). Instrument available from the

National Center for PTSD at www.ptsd.va.gov.

Werner, E. E. (1993). Risk, resilience, and recovery: Perspectives from the Kauai Longitudinal

Study. Development and Psychopathology, 5, 503-515.

Werner, E. E. (2000). In Handbook of early childhood intervention (2nd ed.) [Abstract], by

Werner, Emmy E., 115-132. New York, NY, US: Cambridge University Press.

Werner, E. E., & Smith, R. S. (1992). Overcoming the odds: High risk children from birth to

adulthood. Ithaca, NY: Cornell University Press.

Wolf, E. J., Miller, M. W., Kilpatrick, D., Resnick, H. S., Badour, C. L., Marx, B. P. …

Friedman, M. J. (2015). ICD-11 complex PTSD in US national and veteran samples:

Prevalence and structural associations with PTSD. Clinical Psychological Science: A

Journal of the Association for Psychological Science, 3, 215-229.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural

disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health

Organization.

Yehuda, R. (2004). Risk and resilience in posttraumatic stress disorder. Journal of Clinical

Psychiatry 65(1), 29-36.

Yule, W. (2001). Post-traumatic stress disorder in children and adolescents. International Review

of Psychiatry, 13(3), 194-200.

102
Zeanah, C. H., Boris, N. W., & Larrieu, J. A. (1997). Infant development and developmental

risk: A review of the past 10 years [Abstract]. Journal of the American Academy of Child

and Adolescent Psychiatry, 37(2), 240.

103